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EPITOME     OF 

MENTAL     DISEASES. 


EPITOME     OE 

MENTAL    DISEASES 


■WITH    THE 


Present  Methods  of  Certificatiox  of  the  Insane,   and 
THE  Existing  Regulations  as  to  "Single  Patients/" 

FOR 

PRACTITIONERS    AND    STUDENTS. 


JAMES    SHAW,    M.D.,    Qu.   Univ.,   Irel., 

MASTER  or   SUP.GERY  ; 
MEJIBER   OF  THE    MEDICO-PSTCHOLOGICAl    ASSOCIATION  ; 

rOEMERLY  MEDICAl   SUPEKIXTENDEXT  AND   CO-LICENSEE,  HAYDOCK  LOKGE  ASiLUM, 

LANCASHIRE  ; 

ASSISTANT  MEDICAL   OFFICER,  GROVE   HALL  ASYLUM,  HOW,  LONDON; 

ASSISTANT  MEDICAL  OFFICER,  NORFOLK    COTJNTi    ASYLUM. 


NEW     YORK : 

E.    B.     TREAT,     o,     COOPER    UNIOX. 
1892. 


Joiix    Wr.iGiiT    &    Co., 
Printers   and   Publishkep,   Bristol. 


PREFACE. 

This  work  is  intended  to  be  a  handy  and  practical  book  of 
reference  for  general  practitioners,  and  to  serve  students  as 
an  introduction  to  the  more  comprehensive  treatises  and 
exhaustive  monographs.  Such  a  work  is  necessarily  to  a 
great  extent  a  compilation,  but  it  is  not  altogether  so,  some 
cases  observed  by  me  both  in  asylum  and  private  practice 
having  been  brought  to  bear  on  the  subject,  especially 
in  the  chapters  on  Pathology  and  Treatment  (VII  and 
VIII).  No  new  classification  is  offered,  but  a  few  of 
those  already  proposed  are  given.  These  range  from  the 
simple  one  of  Esquirol,  founded  on  the  still  simpler  but 
time-honoured  one  of  Pinel  (Mania,  Melancholia,  Dementia) 
to  the  elaborate  ones  of  Spitzka  and  Krafft-Ebing,  the 
iatter's  recent  classification  being,  I  think,  as  nearly  perfect 
as  the  present  knowledge  of  encephalic  pathology  permits  it 
to  be.  There  is  one  fault,  however, — the  exclusion  of 
Organic  Dementia ;  it  is  difficult  to  account  for  this  as  the 
mental  troubles  certainly  predominate  in  some  cases. 

A  symptomatic  grouping  of  the  many  forms  (mostly 
etiological)  is  given  at  the  end  of  Chapter  III.  to  bring  them 
more  in  line  with  the  classification  now  commonly  used. 

With  regard  to  some  details  :  The  name  Originare  Para- 
noia (Congenital  Paranoia,  Chap.  I.,  Originary  or  Primitive 
Paranoia)  is  applied  by  Krafft-Ebing  to  the  small  group  of 
cases  of  Paranoia  (Delusional  Insanity),  in  which  the 
disease  develops  at  or.  before  puberty,  the  patient  having 
been  peculiar  mentally  from  early  childhood.  There  are  also 
frequently  physical  disturbances  (pyrexia,  etc.)  and  struc- 
tural peculiarities  (somatic  stigmata),  and  there  is  always 
neurotic  heredity.     The  full  meaning  of  the  term  "  Ver- 


\i  PREFACE. 

bigeration"  will  be  found  in  a  combination  of  the  definition 
given  in  the  "  Contents  "  table  and  the  description  in  the 
text  of  Chap.  II.  Kahlbaum,  who  first  described  the 
symptom,  distinguishes  it  from  maniacal  logorrhcea  on  the 
one  hand  and  idiotic  echolalia  and  babbling  on  the  other. 
It  may  be  mentioned  that  some  authors  believe  cases  of 
"  Katatonia  "  to  be  merely  instances  of  masturbatory  or  of 
adolescent  insanity.  To  the  causes  of  mental  aberration 
given  in  Chap.  IV.,  Influenza  should  be  added.  The 
recently  observed  alternation  of  asthma  and  insanity  is  also 
noteworthy.  In  Chap.  V.  the  component  parts  of  some  of  the 
senses  have  been  separated,  but  merely  for  convenience  of 
investigation ;  as  it  has  been  omitted  there  it  may  be  men- 
tioned here  that  the  thermic  sensibility  is  readily  tested  by 
applying  to  the  skin  several  tubes  containing  water  of 
various  temperatures.  The  condition  of  the  sense  of  weight 
or  muscular  resistance  (pajt  of  the  muscular  sense)  may  be 
ascertained  by  placing  in  the  hands  coins  of  equal  size  but 
different  weight  (the  patient's  eyes  being  closed),  or,  the 
patient's  eyes  being  open,  small  objects  exactly  alike  in 
appearance  but  differing  in  weight  may  be  placed  in  his 
hands  or  suspended  from  his  feet.  When  investigating  the 
muscular  sense  the  patient's  power  of  performing  active 
movements  without  the  aid  of  vision  should  be  tested.  He 
may  be  requested  to  place  a  limb  in  a  given  position,  to 
touch  his  nose,  etc.  In  addition  to  the  test  for  ixissive 
movements  given  in  the  text,  the  leg  may  be  lifted  by  the 
heel,  and  the  patient  asked  to  touch  his  great  toe  with  his 
index  finger.  The  localisation  of  focal  cerebral  disease, 
during  life,  by  means  of  electricity,  has  not  received  notice. 
In  Chap.  VII.  it  will  be  seen  that  the  weight  of  evidence  is 
in  favom'  of  the  view  that  the  foci  of  the  cortical  areas  of 
touch,  of  the  muscular  sense,  and  of  voluntary  motion  are 
almost  co-extensive,  and  are  situated  about  the  middle  of 
the  supero-lateral  surface  of  the  cerebrum,  and  merge 
posteriorly  and  inferiorly  into  the  other  sensory  areas  and 


PREFACE.  Vll 

anteriorly  into  the  higher  emotional  and  volitional  regions. 
It  is  of  interest  to  note  that  all  the  organs  of  sense  are 
derived  originally  from  the  skin,  that  all  knowledge  is  an 
attempt  to  reduce  the  other  senses  to  terms  of  touch,  and 
that,  according  to  Mr.  Herbert  Spencer,  Professor  Bain, 
and  Professor  Wundt,  the  sensation  of  muscular  tension  is 
the  primitive  element  in  our  intelligence.  Dr.  Hughlings 
Jackson  and  other  authorities  have  formulated  the  opinion 
that  every  case  of  insanity  presents  motor  and  sensory 
symptoms  ;  hence  the  utility  of  studying  Organic  Dementia 
in  which  the  underlying  lesions  are  well  marked.  In 
stating  the  hypothesis  as  to  the  genesis  of  sleep,  it  might 
be  added  that  fatigue  assists  the  first  and  second  factors  by 
dimmishing  the  impressionability  of  the  nervous  elements, 
and  by  lessening  cardiac  action  ;  on  the  other  hand  exces- 
sive fatigue  perverts,  or  even  prevents  sleep  by  impairing 
the  contractility  of  the  cerebral  arteries.  Sensation  and 
perception  exclude  each  other,  according  to  Mr.  H.  Spencer, 
with  degrees  of  stringency  which  vary  inversely  :  "  if  the 
sensations  rise  to  extreme  intensity  consciousness  becomes 
so  absorbed  in  them,  that  only  by  great  effort,  if  it  all,  can 
the  thing  causmg  them  be  thought  about."  The  bearing 
of  this  on  the  hypothesis  as  to  hypnosis  will  be  seen  when 
it  is  remembered  that  perceptions  are  almost  entirely 
cortical,  whilst  sensations  are  sub-cortical.  Mr.  Spencer 
explains  the  causation  of  feelings  of  depression  by  low 
nervous  pressure  somewhat  as  follows  : — The  pleasurable 
channels  are  numerous  but  shallow,  whilst  the  painful  ones 
are  few  but  deep  ;  at  low  pressure  many  of  the  shallow 
channels  are  not  permeated  and  the  healthy  equilibrium  is 
disturbed,  the  painful  feelings  predominating.  Sudden 
diminution  of  the  mechanical  pressure  (as  from  haemorrhage 
etc.)  acts  in  a  different  way ;  the  fibres  convey  impulses 
more  readily,  giving  rise  to  convulsions.  Diminished 
mechanical  pressure  may  also  constitute  a  factor  in  the 
pathogenesis  of  the  Ideenjagd  (idea-hunt)  of  the  Germans, 


viii  PREFACE. 

the  inertia  of  the  fibres  being  abnormally  easy  to  overcome, 
though  the  encephalic  nerve  cells  are  weak.  Some  of  the 
views  of  Professor  Meynert,  as  to  Treatment,  Pathology, 
etc.,  given  in  this  work,  have  not  been  quoted  from  books, 
but  from  his  psychiatrical  lectures,  clinical  and  pathological 
demonstrations,  and  explanations  of  macroscopical  and 
microscopical  preparations  during  the  session  1876-77. 
Several  of  the  opinions  and  methods  of  M.  M.  Magnan, 
Luys,  Charcot,  and  Yoisin  have  been  learnt  from  their 
lectures  and  cliniques  during  the  session  1878-79. 

In  using  the  book  for  practical  purposes,  the  chapters 
will  be  most  advantageously  taken  in  the  following  order, 
viz.,  first.  Chap.  II.  (Index  of  Symptoms,  etc.) ;  secondly, 
Chap.  V.  (Diagnosis)  ;  thirdly.  Chap.  III.  (Index  of 
Diseases,  etc.),  and  Chap.  IV.  (Etiology);  the  Prognosis 
(Chap.  VI.)  and  Treatment  (Chap.  VIII.)  being  founded  on 
the  diagnosis  thus  formed;  the  section,  "Morbid  Anatomy 
of  Symptoms"  (Chap.  VII.),  will  also  be  found  useful  in^ 
some  cases. 

Unless  the  case  is  a  very  plain  one,  it  is  advisable  to  see 
the  patient  at  least  twice  before  certifying,  although  the 
essential  part  of  the  certificate  must  be  based  on  the  facts 
observed  at  one  of  the  visits  only.  One  of  the  two  medical 
certificates  required  for  a  private  patient  must  now  be 
signed  by  the  i^atient's  usual  medical  attendant,  if  pos- 
sible. When  it  is  necessary  to  certify,  instructions  for  so 
doing  will  be  found  in  the  final  chapter.  These  instructions 
are  up  to  date  so  far  as  they  relate  to  England  and  Wales, 
Ireland,  and  Scotland,  and  the  State  of  New  York.  If 
the  patient  is  to  be  kept  as  a  single  patient,  the  regula- 
tions as  to  forms  to  be  sent  to  the  Commissioners,  entries 
to  be  made,  etc.,  will  be  found  in  the  same  chapter. 

I  have  to  thank  Dr.  W.  Z.  Myles,  Eesident  ]\Iedical 
Superintendent  of  the  Kilkenny  District  Asylum,  for  most  of 
the  information  as  to  the  method  of  certification  in  Ireland. 


intEFACE. 


Of  the  works  in  the  accompanymg  "  Preference  List,"  I 
am  especial^  indebted  to  the  following,  viz  : — 

Drs.  Bucknill  and  D.  Hack  Tuke's  "  Psychological 
Medicine "  (Churchill)  ;  Dr.  Clouston's  "  Lectures  on 
Mental  Diseases "  (Churchill)  ;  Dr.  Savage's  "  Insanity 
and  Allied  Neuroses  "  (Cassell) ;  Dr.  Spitzka's  "Insanity: 
Its  Classification,  Diagnosis,  and  Treatment";  Dr.  Bra's 
"Manuel  des  Maladies  Mentales";  Dr.  Magnan's  "  Ee- 
cherches  sur  les  Centres  Nerveux  "  (I'alcooHsme,  paralysie 
generale,  etc.);  Dr.  A^oisin's  "  Traite  de  la  Paralysie 
Generale  des  AHenes  ";  Prof.  Griesinger's  "  Die  Pathologie 
und  Therapie  der  Psychischen  Krankheiten  " ;  Prof,  von 
Krafft-Ebing's  "Lehrbuch  der  psychiatrie  " ;  Prof.  Meynert's 
"  Psychiatrie.  Klinik  der  Erkrankungen  des  Vorderhirns, 
begriindet  auf  dessen  Bau,  Leistunge]i  und  Ernahrung, 
Erste  Halfte  " ;  Prof.  Morselh's  "Manualedi  Semejotica 
delle  Malattie  Mentali,"   volumo  primo. 

Thanks  are  due  to  Messrs.  Wright  for  the  careful  and 
painstaking  way  they  have  passed  the  work  through  the 
press,  and  for  the  preparation  of  the  General  Index. 

JAMES   SHAW. 

63,  Kensington,  Liverpool, 
Jamutni,  1892. 


EEFEEENCE   LIST. 

(Bibliography,  limited  to  hooks  and  joiirncds  referred  to  or  consulted.) 

1891,  Lnnaoy  Act. 

„     "A   Plea  for  the   Scientific   Study  of 

Insanity"  -----     Dr.  J.  Batty  Tuke. 

,,     "  Medical  Digest  "         -        -         -        -    Dr.  R.  Neale. 

1890,  "  Lehrbucli  der  Psychiatrie  "  (4Anfl.)-  Prof,  von  Krafpt-Ebing. 
.,     Lunacy  Act. 

,,     "  The  Pulse "        .        -        -        .         .  Dr.  Broadbent. 

,,     "  Sanity  and  Insanity "         -         -        -  Dr.  C.  Mercier. 

1889,  "  The  Treatment  of  Epilepsy  "      -        -     Dr.  W.  Alexander. 
,,     "  Tlie  Causation  of  Disease  "        -        -     Dr.  H.  Campbell. 
,,     "A  Text  Book  of  Mental  Diseases  "      -     Mr.  Bevan  Lewis. 

1888,  "  The  Descent  of  Man  "        -        -        -    Charles  Darwin. 

1887,  "  The  Modern  Treatment  of  Disease  by 

tlie  System  of  Massage  "  -        -        -     Dr.  Stretch  Dowse 
,,     '•  Tlie  Science  of  Thought  "  -         -     Prof.  Max  Muller. 

1886,  "  Clinical  Manual "       -         -         -        -     Dr.  Finlayson. 
,,     "Electricity  in  the  Treatment  of  Dis- 
ease "  -  -  -  -  -  -      Mr.   TUNMER. 

,,     "  Handbook  of  Diseases  of  the  Ear'"     -     Dr.  U.  Pritchard. 
,,     and  1880,   "General   Paralysis   of  the 

Insane  "  (2nd  and  1st  Editions)        -    Dr.  Julius  Mickle. 

1885,  "  The  Blot  uiDon  the  Brain  "  -        -     Dr.  W.  W.  Ireland. 

,,     "  Lectures  on  the  Diagnosis  of  Diseases 

of  the  Brain"   -----     Dr.  Gowers. 
,,     "  Manuale  di  Semejotica  delle  Malattie 

Mentali "  (Vol.  I.)    -        -        -         -     Prof.  Morselli. 
,,     "  Nomenclature  of  Diseases "        -        -     R.  C.  P.  London. 
,,     "Responsibility  in    Mental    Disease" 

(4th  Ed.)  -         -----     Dr.  Maudsley. 

1884,  "  Insanity  and  Allied  Neuroses"    (1st 

Ed.)  ------     Dr.  Savagh. 

,,  "  Psychiatric.  Kltnik  der  Erkrankungen 
des  Vorderhirns,begriindet  auf  dessen 
Bau,  Leistungen  und  Ernahrung." 
Erste  Halfte      -----     Prof.  Mbynert. 

,,     "  Medical  Electricity  "  (2nd  Edition)    -     Dr.  Db  Watteville. 

,,     "  Lectures  on  Mental  Diseases  "   -    '     -     Dr.  W.  H.  O.  Sankey. 

,,  "  Physiological  and  Pathological  Chem- 
istry "       - Dr.  T.  Cranston  Charles. 


REFERENCE   LIST. 


1884,  "  A  Treatise  on  the  Chemical  Constitu- 
tion of  the  Brain  "    - 
,,     "A  Handbook  of  Diseases  of  the  Skin  " 

1883,  "Insanity:    Its   Classification,    Diag- 
nosis, and.  Treatment  "  (1st  Ed.) 
,,     "Lectures  onMentalDiseases"(lstEd.) 
,,     "  Manuel  des  Maladies  Mentales  " 
,,     "  Diseases  of  Memory  "  (2nd  Ed.) 
,,     "  Mind  and  Body:  The  Theories  of  their 
Relation"  (7th  Ed.) 

1882,  "  The  Care  and  Treatment  of  the  Insane 
in  Private  Dwellings  "       - 
,,     "A  Dictionary  of  Medicine  " 
,,     "  Chapters  in  the  History  of  the  Insane 
in  the  British  Isles  " 

1881,  "  Illusions  :  A  Psychological  Study  "     - 
,,     "A   Treatise  on    the   Diseases   of   the 

Nervous  System  "  (1st  Ed.) 
,,     "  The   Factors   of  the   Unsound  Mind 

and  the  Plea  of   Insanity  "     - 

1880,  "The  Brain  as  an  Organ  of  Mind" 
,,     "  Lecons  sur  les  Localisation  C6rebro- 

spinales  " 
,,     "  Brain  and  Nerve  Exhaustion,  Neuras- 
thenia ------- 

,,     "  Physiological  Chemistry  of  the  Animal 
Body "  (Vol.  I.)         -         -         -         - 

1879,  "  A  Manual  of  Psychological  Medicine  " 

(4th  Ed.)  ------ 

,,     "  Trait6  de  la  Paralysie  Generale  des 

Ali^nes  "  - 
„     "Experimental     Researches     on     the 

Regional  Temperature  of  the  Head  " 
,,     "  Principles  of  Mental  Physiology  " 
, ,     "  Syphilis  of  the  Brain  and  Spinal  Cord ' ' 
,,     "A  Manual  of  Medical  Jurisprudence  " 

(10th  Ed.)         .        -         -         -         . 
,,     "  Diseases  of  Modern  Life  " 


Dr. 
Dr. 

Thudichum. 

LiVEING. 

Dr. 
Dr. 
Dr. 
Mor 

Spitzka. 
Clouston. 
Bra. 
is.  Th.  Ribot. 

Prof.  Bain. 

Dr. 
Dr. 

Weatheely. 

QUAIN. 

Dr. 

D.  Hack  Tuke. 

Mr. 

Sully. 

Dr. 

Ross. 

Dr. 

Guy. 

Dr. 

Charlton  Bastian. 

Prof.  Chaecot. 

Dr. 

Stretch  Dowse. 

Dr. 

Gamgee. 

Drs.      BUCKNILL      AND      D. 

Hack  Tuke. 

Dr.  Aug.  Voisin. 

Dr.  Lombard. 

Dr.  Caepenter. 

Dr.  Steetch  Dowse. 

Dr.  Tayloe. 

Dr.  B.  W.  RiCHAEDSON. 


1878,   "  Influence    de    I'Alcoolisme    sur    les 

Maladies  Mentales "  -         -        -     Dr.  Magnan. 

,,     "  Le  Cerveau  et  ses  Eonctions"  (3i^me 

Ed.)  -        ------     Dr.  LuYS. 


1877,  "  Archbold's  Lunacy  "  (2nd  Ed.)  - 

1876,  "  Die  Pathologic  und  Therapie  der  Psy- 
chischen  Eiankheiten  "  (4te  Auf.)  - 
,,  "  Recherches  sur  les  Centres  Nerveux  " 
("  Troubles  de  I'lntelligence  et  des 
Sens  dans  I'Alcoolisme  aigu  et 
chronique,"  etc.)       -        .         .        - 


Mr.  W.  C.  Glen  and  Mr. 
A.  Glen. 

Prof.  Geiesingee. 


Dr.  Magnan. 


Xll  EEFERENOE   LIST. 

1876,  "  The  Functions  of  the  Brain  "  (1st  Ed.)     Prof.  Pereiee. 
, ,     "  Skizzen  iiber    Unif ang    und    wissen- 
chaftliche  Anordnung  der  Klinischen 
Psychiatrie "    -         -         -         -         -     Prof.  Meynekt. 

1875,  "  Paralysis  from  Brain  Disease  "  -        -     Dr.  Chaelton  Bastias. 

1874,  "  Manual  of  Lunacy"  -        -         -     Dr.  L.  S.  Wixslow. 

1873,  "  Body  and  Mind  "         -         -         -         -     Dr.  Maudsley. 

,,     "  AUegeineine    Pathologie    der  Krank- 

heiten  des  Nervensystems,"  I.  Theil     Prof.  Hugnexin. 
1872,  "  The  Influence  of  the  INIind  upon  the 

Body"       -         -        -         -        -         -     Dr.  D.  Hack  Tuke. 

,,     •'  Der  Bau   der    Gross-Hirnrinde    und 

seine    ortlichen    Verschiedenheiten 

nebst   einem  pathologisch-anatonii- 

schen  Corollarium "  -         -         _     Prof.  Meyneet. 

, ,     '  ■  The  Expression   of  the  Emotions  in 

Man  and  Animals  "  -        -        -        -     Charles  Daewix. 

1871,  "  Lectures  on  Insanitjr  "  (1st  Ed.)        -     Dr.  Blaxdfoed. 
,,     "  The   Use   of  the  Ophthalmoscope  in 

Diseases  of  the  Nervous  System  "     -     Dr.  Clifeoed  Allbutt. 

1870,  "  The ,  Principles  of  Psj^chology  "  (2nd 

Ed.)  -------     Mr.  Heebeet  Spenceb. 

1868,  "The    Physiology    and    Pathology    of 

Mind"  (2nd  Ed.)      -        -        -'       -     Dr.  Maudsley. 

The  "  Medical  Annual." 

"  Braithwaite's  Retrospect." 

The  "Liverpool  Medico-Ghirurgical  Journal." 

The  "  Journal  of  Mental  Science." 

"Bram." 

"  Die  AUgemeine  Zeitschrift.  fiir  Psychiatrie." 

The  "Journal  of  Nervous  and  Mental  Diseases." 

"  L'Encephale." 

"  Lidex  jMedicus." 

The  "  Provincial  Medical  Journal." 

The  "  Lancet." 

The  "  British  ]Medical  Journal." 

The  "  Medical  Press  and  Circular." 

"  Le  Progres  Medical." 

"  Le  Mercredi  I\Iedical." 

"  Gsntraiblatt  fiir  die  ]Medicinischen  Wissenschaften." 


CONTENTS. 


CHAPTER  I. 

DEFINITIONS  OP  INSANITY   AND   CLASSIFICATION 

OF  MENTAL  DISEASES    -----  page  I 

Definitions — Classifications — Esquirol's — Commissioners' — Morel's — 
Of  International  Congress  of  Alienists — Skae's — Krafit-Ebing's — 
Bra's — Clouston's — Spitzka's— Savage's  grouping — Of  London  Col- 
lege of  Physicians — Krafft-Ebing's  Recent. 

CHAPTER  11. 

INDEX  OF  SYMPTOMS  SOMATIC,  PHYSI0L0GIC-4L, 
-\ND  PSYCHICAL,  WITH  THE  MENT-4L  DISEASES 
IN   WHICH   THEY    OCCUR  .  -  .  -         page  11 

Abulia  — Amnesia — Attention,  defective  —  Bulimia  —  Consciousness 
impaired — Delusions — Emotional  disturbances — Facial  alterations 
— Grip  or  hand-grasp,  feeble  — HaUucinations — Illusions — Impera- 
tive conceptions  or  obsessions — Impulsive  acts — Loquacity — Morbid 
propensities — Mutism —  Noisiness — Optic  laerve  changes — Paralysis 
— Pupils,  alterations  of  —Pulse  changes — Reaction  time— Restless- 
ness— Retina,  changes  in — Sexual  perversion — Somatic  stigmata — 
Speech,  abnormalities  of — Temperature  changes — Tongue  changes 
— Tremor  —  Urine,  alterations  in — Verbigeration  (a  continued 
repetition  of  ineaningless  or  disconnected  sounds,  words,  or  phrases. 
Kahlbaum) — Weeping — "  W^et  "  in  habits — Writing  altered,  etc., 
etc. 

CHAPTER   III. 

INDEX      OF      I\IENTAL     DISEASES     WITH      THEIE 

SYNONYjMS  and  SYMPTOMS      -  -  -  .         page  49 

-\bdominal  Disorders  (uasanity  from) — Adolescent  Insanity — Antemic 
Insanity — Bright's  Disease  (insanity  of)— Cataleptic  Insanity — 
Choreic  Insanity — Circular  Insanity — Climacteric  Insanity— Coarse 
Brain  Disease  (insanity  from) — Confusional  Insanity — Consecutive 
Insanity—  Cyanosis  from  Bronchitis,  Cardiac  Disease  and  Asthma 
(insanity  of)— Delirium,  acute — Delusional  Insanity  (paranoia) — 
Dementia,  Terminal— Deprivation  of  Senses  (insanity  from) — 
Diabetic  Insanity  —  Epileptic  Insanity  — Exoi^hthalmic  Goitre 
(insanity  v^^ith)— Fohe  a  Deux— Fohe  du  Doute— General  Paralysis 
of  the  Insane — Gestational  Insanitj' — Hypochondriasis — Hysteri- 


XIV  CONTENTS. 

cal  Insanity — Idiocy  (including  Imbecility  and  Cretinism)  — 
Impulsive  Insanity — Katatonic  Insanity — Lactational  Insanity-— 
Mania — Masturbational  Insanity — Melancholia — Mental  Deteriora- 
tion, Primary — Metastatic  Insanity — Moral  Insanity — Myxoedema 
(insanity  of) — Neurasthenia  and  Neurasthenic  Insanity — Ovarian 
or  Old  Maid's  Insanity — Oxaluria  and  Phosphaturia  (insanity  of) 
— Paralysis  Agitans  (insanity  of) — Partial  Emotional  Aberration — 
Partial  Exaltation  or  Amenomania — Pellagrous  Insanity — Period- 
ical Insanity — Phthisical  Insanity — Podagrous  or  Gouty  Insanity 
— Post-Connubial  Insanity — Pubescent  Insanity — Puerperal  In- 
sanity —  Eeasoning  Insanity  (Folic  Raisonnante)  —  Rheumatic 
Insanity — Senile  Insanity — Somnambulism  (Pseiido-Insanity  of) — 
Stupor,  Anergic — Syphilitic  Insanity — Toxic  Insanity — TrsAimatic 
Insanity — Uterine  or  Ameuorrhceal  Insanity — Young  Children, 
Delirium  of. 

Grouping  of  the  foregoing  forms  of  Mental  Aberration  according  to 
one  or  two  of  the  most  prominent  symptoms. 

I.  Mental  Pain  or  Hindrance  (Hampering)  of  Mental  Action,  or  both — 
II.  Emotional  Exaltation,  or  Excitement  (Mental  or  Motor),  or 
both — III.  Delusion,  Hallucination,  Fixed  Idea  (Obsession),  Morbid 
Impulse,  or  Extraordinary  Actions — IV.  Acquired  Mental  Weak- 
ness— V.  Acquired  Mental  Weakness  with  Delusions  and  Hallu- 
cinations— VI. — Acquired  Mental  Weakness  with  Paresis — VII. 
Acquired  Mental  Weakness  with  Paralysis — VIII.  Stupor — IX. 
Delirium  with  Unconsciousness — X.  Congenital,  Mental  or  Moral 
Weakness. 

CHAPTER  IV. 

ETIOLOGY      -------  PAGE  134 

A.  General:  Causes  of  Insanity  in  England  and  Wales  from  1878  to 
1887  ;  Predisposing  Causes  ;  Exciting  Causes — B.  Special  (Causes 
of  the  various  forms  of  Insanity). 

CHAPTER  V. 

DIAGNOSIS    -  -  -  -  -  -  -  PAGE  146 

A  Diagnosis  of  Insanity  from  other  conditions  (Eccentricity,  Feigned 
Insanity,  the  Delirium  of  Fevers  and  Inflammations,  Alcoholic 
or  other  Intoxication,  Cerebral  Meningitis,  Aphasia) — Method 
of  Examining  a  Patient — To  investigate  the  Acuteness,  etc.,  of  the 
various  Senses  (touch,  smell,  taste,  hearing,  vision,  and  the 
muscular  sense) — Description  of  Mental  and  Bodily  Condition  on 
Admission  (to  be  made  in  "Case  Book") — B.  Differential  Diag- 
nosis of  the  Forms  of  Insanity — Alphabetical  List  of  Mental 
Diseases  with  References  to  the  preceding  Paragraphs — Frequency 
of  Principal  Forms. 

CHAPTER   VI. 

PROGNOSIS  --.---.  PAGE  171 

A.  General  Prognosis — I.  As  to  Danger  to  Life — II.  As  to 
Recovery  from  Mental  Derangement — B.  Special  Prognosis  (in- 
cluding duration) — Most  of  the  Forms  in  alphabetical  order. 


CONTENTS. 


CHAPTER  VII. 

PATHOLOGICAL      ANATOMY,       PATHOLOGY,      AND 
PATHOGENESIS      ------        page  189 

Morbid  Anatomy  :  A.  General  (encephalic) — B.  Sjpecial  (encephalic) — 
C.  Morbid  Anatomy  (encephalic)  of  Symptoms  (sensory,  motor, 
emotional,  etc.) — D.  Lesions  of  Non-Nervous  Organs,  Tissues,  etc. 

Pathology  and  Pathogenesis  :  General  Considerations — Cortical  Cells 
and  their  Connections — Central  Ganglia — Sleep,  Hj'pothesis  as  to 
Physiology  of — Cerebrum  and  Cerebellum — Hypothesis  as  to 
Functions  of  Cerebelluin — Somnambulism — Hyx^notism — Effects 
on  Brain  of  Impressions  from  Abdominal  and  Thoracic  Viscera — 
Effects  of  Cerebral  Nutrition — Insanity  in  Children — Pathogenesis 
of  Symj)toms — Symptoms  that  are  seldom  absent — Climacteric 
Insanity. 

CHAPTEE  VIII. 

THERAPEUTICS  AND  HYGIENE  -  -  -  page  2-12 

Prophylaxis :  Remedial  Treatment. — I.  The  immediate  relief  of 
Urgent  Symptoms,  Insomnia,  Excitement,  Sitophobia,  Suicidal 
or  Homicidal  Tendencies,  etc. — II.  Ultimate  Care  and  Treatment 
A.  Home  Treatment — B.  Private  Care  (Single  Patients) — C. 
Asylum  Treatment  and  Care:  1.  Pauper  Asylums;  2.  Lunatic 
Hospitals  ;  3.  Private  Asylimis.  Treatment  of  some  of  the  Forms 
of  Insanity. 

CHAPTER  IX. 

LEGAL  REGULATIONS  &  FORENSIC  PSYCHIATRY  -  page  2G9 
Certification  of  Insane  Private  Patients  in  England  and  Wales — 
Voluntary  Boarders — Laws  as  to  Keeping  Single  Patients  in 
England  and  Wales — Chancery  Patients — Uncertified  Lunatics — 
Pauper  Lunatics — Lunatics  (not  Paupers)  not  under  proper  Care 
and  Control  or  Cruelly  Treated  or  Neglected — Wandering  Lunatics 
— Criminal  Lunatics — Certification  of  the  Insane  in  Scotland — 
Certification  of  the  Insane  in  Ireland — Certification  of  the  Insane 
in  the  State  of  New  York — Certification  of  the  Insane  in  the  States 
of  Connecticut,  Pennsylvania,  Massachusetts,  and  Illinois — Testa- 
mentary Capacity  of  the  Insane — Evidence  (Testimouj^)  of  the 
Insane — Legal  Tests  of  Insanity  and  Legal  Responsibility  of  the 
Insane. 


GENERAL    INDEX. 


Epitome  of  Mental  Diseases. 


CHAPTER   I. 


DEFINITIONS    OF   INSANITY   AND    CLASSIFICATIONS 
OF  MENTAL  DISEASES. 


DEFINITIONS. 

FROM  the  physician's  point  of  view  insanity  has  to  be  con- 
sidered as  a  disease  of  the  brain  or  a  disorder  of  the  mind, 
quite  apart  from  any  consideration  of  responsibility  whatever 
(Savage).  A  man  must  be  considered  as  sane  or  insane  in  relation 
to  himself  (Savage).  The  statement  that  insanity  is  a  perversion 
of  the  ego  is  absolutely  true  (Savage).  The  last  two  statements 
manifestly  exclude  congenital  mental  defects.  Alteration  of 
sentiments,  disposition,  and  conduct  in  a  morbid  manner  is 
sufficient  to  constitute  an  individual  insane  without  the  presence 
of  a  delusion  (Griesinger).  A  disease  of  the  brain  (idiopathic  or 
sympathetic)  affecting  the  integrity  of  the  mind  whether  marked 
by  intellectual  or  emotional  disorder,  such  affection  not  being  the 
mere  symptom  or  immediate  result  of  fever  or  poison  (Bucknill 
and  Tuke). 

Insanity  may  be  (a,)  Congenital,  the  mental  powers  or  moral 
character  being  much  below  the  normal  average  standard  at  the 
same  age  ;  or  {h,)  Acquired,  the  original  character  of  the  patient 
being  morbidly  altered  (See  "Legal  Tests"  of  Insanity, 
Chap.  IX.). 

1 


2  DEFINITIONS   OF   INSANITY  AND 

CLASSIFICATIONS. 
Esqirol's  Classification   (founded  on  Pinel's). 

(1,)  Lypemania  (Melancholy  of  the  ancients) ;  (2,)  Monomania  ; 
(3,)  Mania  ;  (4,)  Dementia  ;  (5,)  Imbecility  or  Idiocy. 

The  Principal  Forms  of  Insanity  are  classified  by  the 
Commissioners  in  their  Report   (1844)  under 

THE  following  HeADS  : — 

I. — Mania,  which  is  thus  divided  :  (1,)  Acute  Mania  or 
Raving  Madness  ;  (2,)  Ordinary  Mania,  or  Chronic  Madness  of  a 
less  acute  form;  (3,)  Periodical,  or  Intermittent  Mania,  with 
comparatively  lucid  intervals. 

II. — Dementia,  or  deciiy  and  obliteration  of  the  intellectual 
faculties. 

III.  — Melancholia. 
IV. — Monomania. 
V. — Moral  Insanity. 

(The  three  last  mentioned  forms  are  sometimes  comprehended   under 
the  term  Partial  Insanity.) 

VI. — Congenital  Idiocy. 
VII. — Congenital  Imbecility. 
VIII. — General  Paralysis  of  the  Insane. 
IX. — Epilepsy. 

X. — Delirium  Tremens,  which  may  perhaps  be  added  to  these 
heads,  since  it  is  mentioned  as  a  form  of  insanity  in  the  reports 
of  some  lunatic  asylums  ("  Archbold's  Lunacj^,"  2nd  Ed.,  p. 
651). 

Morel's    Classification    (about    1860)     principally 
SoMATo. — Etiological. 

Group  I. — Hereditary  Insanity  :  Class  1. — Those  who  are  of 
congenitally  nervous  temperament ;  2. — Those  whose  insanity  is 
indicated  by  insane  acts  rather  than  insane  conversation.  Includes 
Prichard's  Moral  Insanity ;  3. — Constitutes  the  transition  state 
between  Class  2,  and  idiots  and  imbeciles.  The  members  of  this 
class  are  marked  by  morbid  impulses  to  incendiary  acts,  theft, 
etc.  ;  4. — Idiots  and  Imbeciles. 

Group  II. — Toxic  Insanity  :  Class  1. — Caused  by  intoxicating 
substances  as  alcohol,  opium,  etc.  Also  poisonous  ingredients  as 
lead,  mercury,  etc.  ;  2. — Caused  by  insufficient  or  diseased  food, 
as  ergot  of  rye  ;  3. — Caused  by  Marsh  Miasma  or  the  geclogical 
constitution  of  the  soil  {e.g.,  Cretinism). 


CLASSIFICATIONS    OF  MENTAL   DISEASES.  3 

Group  III. — Insanity  produced  hy  the  transformation  of  other 
cases:  Class  1. — Hysterical  Insanity;  2. — Epileptic  ditto;  3. — 
Hypochondriacal  ditto,  consisting  of  three  varieties. 

Group  IV. — Idiopathic  Insanity  :  Class  1. — Progressive  weaken- 
ing or  abolition  of  the  intellectual  faculties,  resulting  from  chronic 
disease  of  the  brain  or  its  membranes  ;  2. — General  Paralysis. 

Group  V. — Sympathetic  Insanity. 

Group  VI. — Dementia  "a  terminative  state"  ("Bucknill  and 
Tuke,"  pp.  40-41). 

Classification  proposed   by  the  International  Congress 
OF  Alienists   (Paris  1867). 

(1,)  Simple  Insanity  comprehends  the  different  varieties  of 
Mania,  Melancholia,  and  Monomania,  Circular  Insanity,  and 
Mixed  Insanity,  Delusion  of  Persecution,  Moral  Insanity,  and  the 
Dementia  following  these  different  forms  of  insanity. 

(2,)  Epileptic  Insanity  means  insanity  with  Epilepsy,  whether 
the  convulsive  affection  has  preceded  the  insanity  and  has  seemed 
to  have  been  the  cause,  or  has  appeared  during  the  course  of  the 
mental  disease,  only  as  a  symptom  or  comj^lication. 

(3,)  Paralytic  Insanity  or  Dementia  should  be  considered  as  a 
distinct  morbid  entity,  and  not  at  all  as  a  complication,  a  termin- 
ation of  certain  forms  of  Insanity.  There  should  be  comprehended, 
then,  under  the  name  of  Paralytic  Insane,  all  the  insane  who  show 
in  any  degTee  whatever,  the  characteristic  symptoms  of  this 
disease. 

(4,)  Senile  Dementia  is  the  slow  and  progressive  enfeeblement 
of  the  intellectual  and  moral  faculties  consequent  upon  old  age. 

(5,)  Organic  Dementia  embraces  all  the  varieties  of  Dementia 
other  than  the  preceding,  and  Avhich  are  caused  by  organic  lesions 
of  the  brain,  nearly  always  local,  and  presenting,  as  almost  con- 
stant symptoms,  hemif)legic  occurrences  more  or  less  prolonged. 

(6,)  Idiocy  is  characterised  by  the  absence  or  arrest  of  the 
development  of  the  intellectual  and  moral  faculties.  Imbecility 
and  Weakness  of  Mind  constituting  two  degrees  or  varieties. 

(7,)  Cretinism  is  characterised  by  a  lesion  of  the  intellectual 
faculties,  more  or  less  analogous  to  that  observed  in  Idiocy, 
but  mth  which  is  uniformly  associated  a  characteristic  vicious 
conformation  of  the  body,  an  arrest  of  the  development  of  the  en- 
tirety of  the  organism. 

Under  the  titles  "  Ill-defined  Forms,"  "  Other  Forms,"  are  to 
be  set  down  all  the  varieties  of  Mental  Alienation  which  it  shall 
seem  impossible  to  associate  with  any  of  the  precedino-  tymcal 
forms  ("Bucknill  and  Tuke,"  pp.  45-46). 


DEFINITIONS   OF   INSANITY  AND 


Skae's   Classification,   essentially   though    not    wholly 
Etiological. 


Moral    and   Intellectual 

Mania  of  Oxaluria  and 

Idiocy  and  Imbecility 

Phospbaturia 

Epileptic  Insanity 

Senile  Mania 

Insanity  of  Mastm-bation 

Phthisical  Mania 

Insanity  of  Pubescence 

Metastatic  Mania 

Hysterical  Mania 

Traumatic  Mania 

Amenorrboeal  Mania 

Syphilitic  Mania 

Post-connubial  Mania 

Delirium  Tremens 

Puerperal  Mania 

Dipsomania 

Mania  of  Pregnancy 

Mania  of  Alcoholism 

Mania  of  Lactation 

General  Paralj^sis  with 

Climacteric  Mania 

Insanity 

Ovario-Mania  (Utero-Mania) 

Epidemic  Mania 

Post-febrile  Mania 

Idiopathic 

1 

Sthenic 

Insanity 

/ 

Asthenic 

Krafft-Ebing's  Classification  ("Lehebuch  der  Psychiatrie," 
1879.     From  Spitzka.'s  "Insanity,"  pp.  116-117). 

Group  A. — Mental  affections  of  the  developed  brain. 

I. — Psychonenroses  : — 

(1,)  Primary  curable  conditions 

(a,)  Melancholia  ;  («,)  Melancholia  passiva  ;  {/3,)  Melancholia 
Attonita. 

(b,)  Mania  :  (a,)  Maniacal  Exaltation  ;  (fi,)  Maniacal  Frenzy. 

(c,)  Stupor. 

(2,)  Secondary  incurable  states. 

{«,)  Secondary  monomania  (Secundare  Yerriicktheit). 

(h,)  Terminal  dementia  ;  (a,)  Dementia  agitata  ;  (/3,)  Dementia 
Apathetica. 

II. — Psychical  Degenerative  States  : — 

(a,)  Constitutional  affective  insanity  (folie  raisonnante) 

(b,)  Moral  insanity. 

(c,)  Primary  monomania  (primare  Yerriicktheit) :  (a,)  With 
delusions ;  (aa,)  Of  a  persecutory  tinge  ;  {^(3,)  Of  an  ambitious 
tinge  ;  (^,)  With  imperative  concej)tions. 

(d,)  Insanities  transformed  from  the  constitutional  neuroses  ; 
(a,)  Epileptic  ;  (/S,)  Hysterical ;  (y,)  Hypochondriacal. 

(e,)  Periodical  insanity. 

III. — Brain  Diseases  with  Predominating  Mental  Symptoms  : — 

{a,)  Dementia  paralytica. 

{!),)  Lues  cerebralis. 


CLASSIFICATIONS   OF   MENTAL   DISEASES  5 

(e,)  Chronic  alcoliolisni. 
(d,)  Senile  dementia. 
(e,)  Acute  delirium. 

Group  B. — Mental  Results  of  Arrested  Brain  Development, 
Idiocy  and  Cretinism. 

Bra's    Classification,     1883    ("Manuel    des   Maladies 

Mentales.")  Based  on  Etiology.    Founded  on  the 

Classifications  of  Ball  and  Morel  : — 

(1,)  Vesanic  (without  actually  well  determined  lesions).  General 
delirium  ;  mania,  melancholia,  folie  circulaire.  Partial  delirium  ; 
delirium  of  persecution,  religious  insanity,  mania  of  suspicion, 
dipsomania. 

(2,)  Neuropathic. — Hysterical ;  epileptic  ;  choreic  ;  cataleptic, 
etc. 

(3,)  Diathetic. — Gouby ;  tuberculous  ;  syphilitic. 

(4,)  Sympathetic. — Genital ;  puerperal. 

(5,)  -Toxic. — Alcoholic;  saturnine. 

(6,)  Organic. — ^ Acute  delirium  ;  general  paralysis  ;  dementia. 

(7,)  Congenital  or  Morphological. — Idiocy ;  imbecility ;  cretin- 
ism. 

ClOUSTON'S    SYMPTOaiATOLOGICAL   CLASSIFICATION,    1883, 

("Clinical  Lectures  on  Mental  Diseases," 
pp.  19-20). 

(1,)  States  of  mental  depression  (melancholia,  psychalgia) : — 
{a,)  Simple  melancholia  ;  (/),)  Hypochondriacal  melancholia  ;  (c,) 
Delusional  Melancholia  ;  [cl,)  Excited  melancholia  ;  (e,)  Resistive 
(obstinate)  melancholia  ;  (/,)  Convulsive  melancholia  ;  {g,)  Organic 
melancholia  ;  (/i,)  Suicidal  and  homicidal  melancholia. 

(2,)  States  of  mental  exaltation  (mania,  psychlampsia) : — [a,) 
Simple  mania;  (&,)  Acute  mania;  (c,)  Delusional  mania;  (d,) 
Chronic  mania;  {e,)  Ephemeral  mania  (mania  transitoria) ;  (/,) 
Homicidal  mania. 

(3,)  States  of  regularly  alternating  mental  conditions  (folie 
circulaire,  j^sychorj'thm,  folie  a  double  forme,  circular  insanity, 
periodic  mania,  recurrent  mania,  katatonia). 

(4,)  States  of  fixed  and  limited  delusion  (monomania,  mono- 
psychosis) : — («-,)  Monomania  of  pride  and  grandeur  ;  (&,)  Mono- 
mania of  unseen  agency  ;  (c,)  Monomania  of  suspicion. 

(5,)  States  of  mental  enfeeblement  (dementia  and  amentia, 
psychoparesis,  congenital  imbecility,  idiocy) : — (a,)  Secondary 
(ordinary)  dementia  (following  mania  and  melancholia) ;  (h,) 
Primary  enfeeblement  (imbecility,  idiocy,  cretinism,  the  result  of 
deficient  brain  develoj^ment,  or  of  brain  disease  in  very  early  life) ; 


•6  DEFINITIONS   OF   INSANITY   AND 

(c,)  Senile  dementia  ;  {d,)  Organic  dementia  (the  result  of  gTOSs 
organic  brain  disease). 

(6,)  States  of  mental  stupor  (stupor,  psychocoma) : — {a,) 
Melancholic  stupor,  " melancholia  attonita"  ;  (&,)  Anergic  stupor, 
primary  dementia,  "dementia  attonita";  (c,)  Secondary  stupor 
(transitory  after  acute  mania). 

(7,)  States  of  defective  inhibition  (psychokinesia  hyperkinesia, 
impulsive  insanit}^,  volitional  insanity,  uncontrollable  impulse ; 
insanity  without  delusion): — («,)  General  impulsiveness ;  (6,) 
Epileptiform  impulse;  (c,)  Animal,  sexual,  and  organic  impulse ; 
{d,)  Homicidal  impulse  ;  ((?,)  Suicidal  impulse  ;  (/)  Destructive 
impulse;  {g,)  Dipsomania;  Qi,)  Kleptomania;  (i,)  Pyromania; 
(li,)  Moral  insanity. 

(8,)  The  insane  diathesis  (psychoneiurosis,  neurosis  insana, 
neurosis  spasmodica). 

Clouston's  Clinical  Classification  (02).  cit.  p.  21),  including 
THE  Pathological  Varieties  of  Mental  Disease. 

(1,)  General  paralysis ;  (2,)  Paralytic  insanity  (organic 
dementia);  (3,)  Traumatic  insanity ;  (4,)  Epileptic  insanity  ;  (5,) 
Syphilitic  insanity  ;  (6,)  Alcoholic  (and  toxic)  insanity  ;  (7,)  Rheu- 
matic and  choreic  insanity;  (8,)  Gouty  (podagTous)  insanity; 
(9,)  Phthisical  insanity  :  (10,)  Uterine  insanity ;  (11,)  Ovarian 
insanity;  (12,)  Hysterical  insanity;  (13,)  Masturbational  in- 
sanity; (14,)  Puerperal  insanity;  (15,)  Lactational  insanity; 
(16,)  Insanity  of  pregnancy;  (17,)  Insanity  of  puberty  and 
adolescence;  (18,)  Climacteric  insanity;  (19,)  Senile  insanity. 
With  a  number  of  more  rare  and  less  important  varieties,  viz  : — (1,) 
Anaemic  insanity ;  (2,)  Diabetic  insanity;  (3,)  Insanity  from 
Bright's  disease  ;  (4,)  The  insanity  of  oxaluria  and  phosphaturia ; 
(5,)  The  insanity  of  cyanosis  from  bronchitis,  cardiac  disease  and 
asthma;  (6,)  Metastatic  insanity  ;  (7,)  Post-febrile  insanity  ;  (8,) 
Insanity  from  dejorivation  of  the  senses  ;  (9,)  The  insanity  of 
myxoedema ;  (10,)  The  insanity  of  exophthalmic  goitre;  (11,) 
The  delirium  of  young  children;  (12,)  The  insanity  of  lead 
poisoning;  (13,)  Post-connubial  insanity;  (14,)  The  pseudo- 
insanity  of  somnambulism. 

Spitzka's  Classification    ("Insanity,    its   Classification," 
Etc.,  p.  126)  1883. 

Group  First,  Pure  Insanities. 

Sub-Group  (A,) — Simple  insanity,  not  essentially  the  manifesta- 
tion of  a  constitutional  neurotic  condition. 

First  Class. — -Not  associated  with  demonstrable  active  organic 
changes  of  the  brain. 


CLASSIFICATIONS   OF  MENTAL   DISEASES.  7 

I.  Division.^ — Attacking  the  individual  irrespective  of  the 
physiological  periods. 

(a,)  Order  of  primary  origin. 

Sub-Order  (A,) — Characterised  by  a  fundamental  emotional  dis- 
turbance : — 

Genus  (1,)  Of  a  pleasurable  and  expansive  character — Simple 
Mama. 

Genus  (2,)  Of  a  painful  character — Simple  Melancholia. 

Genus  (3,)  Of  a  pathetic  character — Katatonia. 

Genus  (4,)  Of  an  explosive  transitory  kind — Transitory  Frenzy. 

Sub-Order  (B,) — Not  characterised  by  a  fundamental  emotional 
disturbance  : — 

Genus  (5,)  With  simple  impairment  or  abolition  of  mental 
energy — Stuporous  Insanity. 

Genus  (6,)  With  confusional  delirium — Prinmry  Confusional 
Insanity. 

Genus  (7,)  With  uncomplicated  progi^essive  mental  impair- 
ment— Primary  Deterioration. 

(/3,)  Order:  Of  secondary  origin  : — 

Genus  (8,)  Secondary  Confusional  Insanity. 

Genus  (9,)  Terminal  Dementia. 

II.  Division. — Attacking  the  individual  in  essential  connection 
with  the  developmental  or  involutional  periods  (a  single  order). 

Genus  (10,)  With  senile  involution — Senile  Dementia. 

Genus  (11,)  With  the  period  of  puberty — Insanity  of  Pubescence 
(Hebephrenia). 

Second  Class. — Associated  with  demonstrable  active  organic 
changes  of  the  brain  (orders  coincide  with  genera). 

Genus  (12,)  Which  are  diffuse  in  distribution,  primarily  vaso- 
motor in  origin,  chronic  in  course  and  destructive  in  their  results 
— Paretic  Dementia. 

Genus  (13,)  Having  the  specific  luetic  character — Sypihilitic 
Dementia. 

Genus  (14,)  Of  the  kind  ordinarily  encoimtered  by  the  neuro- 
logist, such  as  encephalomalacia,  haemorrhage,  neoplasms,  menin- 
gitis, parasites,  etc. — Dementia  from  Coarse  Brain  Disease. 

Genus  (15,)  Which  are  primarily  congestive  in  character  and 
furibund  in  development — Delirium  Grave  (Acute  Delirium, 
Manie  grave). 

Sub-Group  (B,) — Constitutional  insanity,  essentially  the  expres- 
sion of  a  continuous  neurotic  condition. 

Third  Class. — Dependent  on  the  great  neuroses  (orders  and 
genera  coincide). 

I.  Division. — The  toxic  neuroses  : — 

Genus  (16,)  Due  to  alcoholic  abuse — Alcoholic  Insanity. 


8  DEFINITIONS   OF  INSANITY  AND 

(Analogous  forms,  such  as  those  clue  to  abuse  of  opium,  the  bromides, 
and  chloral,  need  not  be  enumerated  here  owing  to  their  rarity.) 

II.  Division. — The  natm'al  neuroses  : — 

Genus  (17,)  The  hysterical  neur'osis — Hysterical  Insanity. 

Genus  (18,)  The  epileptic  neurosis — Epileptic  Insanity. 

Fourth  Class. — Independent  of  the  great  neuroses  (representing 
a  single  order). 

Genus  (19,)  In  periodical  exacerbations — Periodical  Insanity. 

Order. — Arrested  deA^elopment : — 

Genus  (20,)  Idiacy  and  Imbecility. 

Genus  (21,)  Cretinism. 

Genus  (22,)  Manifesting  itself  in  primary  dissociation  of  the 
mental  elements,  or  in  a  failure  of  the  logical  inhibitory  power,  or 
of  both — Monomania. 

Group  Second,  Complicating  Insanities. — These  may  be 
divided  into  the  folloAving  main  orders,  -which,  as  a  general  thing, 
are  at  the  same  time  genera :  traumatic,  choreic,  iKist-fehrilr, 
rheunmtic,  gouty,  plitldsv-al,  sympathetic,  pellagrous. 

Savage  jmakes  use  of  the  following  Groups    ("Insanity 
AND  Allied  Xeuroses,"  p.  12,  1884). 

Hysteria — mania  ;  hypochondriasis — melancholia  ;  Dementia, 
general  and  partial,  primary  and  secondary ;  states  of  mental 
weakness — chronic  mania  and  melancholia  ;  recurrent  insanity  : 
delusional  insanity  ;  general  pai^alysis  of  the  insane  ;  paralytic 
insanity — epileptic  insanity  ;  puerperal  insanity — post-connubial, 
puerperal,  lactation  ;  toxic  insanity — alcohol,  lead,  opium,  chloral, 
gout,  etc. ;  ^dsceral  insanity — renal,  cardiac,  pulmonary ;  insanity 
■with  syphilis — myxcedema — Graves'  disease — asthma — diabetes  : 
idiocy  in  its  various  forms. 

Classification  adopted  by  the  Committee  of  the  London 

College  of  Physicians,  1885     ("  Nomenclature 

OF  Diseases,"  pp.  29-31). 

They  divide  Mental  Diseases  into  Hypochondriasis  and  Insanity, 
and  sub-divide  Insanity  into  : — Mania  ;  melancholia ;  dementia; 
including  acquired  imbecility ;  idiocy,  synonym,  congenital 
imbecility  ;  general  paralysis  of  the  insane  ;  puerperal  insanity  : 
epileptic  insanity ;  insanity  of  puberty ;  climacteric  insanity  : 
senile  insanity ;  toxic  insanity,  from  alcohol,  gout,  lead,  etc., 
variety,  delirium  tremens  ;  traumatic  insanity  ;  insanity  associated 
with  obAdous  morbid  change  or  changes  in  the  brain ;  consecutive 
insanity,  from  fevers,  visceral  inflammations,  etc. 


CLASSIFICATIONS   OF   MENTAL   DISEASES.  9 

Note. — So-called  cases  of  monomania  should  be  named  according  as  the 
prevailing  symptoms  are  those  of  mania,  melancholia,  or  dementia  ;  and 
distinct  hereditary  tendency  should  be  mentioned. 

Krafft-Ebing's  Recent  Classification  (Lehrbuch  der 
PSYCHIATRIE,  4tli  Ecl,  1890,  pp.  325-326). 

A. — Psychical  affections  of  the  developed  brain. 

I.— Diseases  Avithout  any  discernible  lesion — functional  psy- 
choses. 

AA. — Psychoneuroses,  that  is  to  say,  diseased  conditions  of  the 
normally  constituted  and  previously  healthy  brain. 

(1,)  Melancholia  (inhibiting  neurosis  of  ,the  psychical  organ)  : 
{a,,)  Melancholia  simplex  ;  (h,)  Melancholia  cum  stupore. 

(2,)  Mania  (discharging  neurosis)  :  (a,)  Maniacal  exaltation  ; 
(/;,)  Maniacal  Frenzy  {tohsucM). 

(3,)  Stupor  or  acute  and  curable  dementia  (neurosis  of 
exhaustion). 

(4,)  Hallucinatory  delirium,  hallucinatory  psychoneurosis 
(Wahnsinn). 

Chronic  mania  or  chronic  confusional  insanity  (secundjire  Ver- 
riicktheit)  and  secondary  dementia  are  terminal  incurable  states  of 
the  above  four  conditions.  There  are  two  clinical  varieties  of 
secondary  dementia,  viz.,  agitated  and  apathetic. 

BB. — Psychical  degenerative  states,  that  is  to  say,  affections  of 
the  morbidly  constituted  or  weakened  brain. 

(l,j  Constitutional  affective  insanity  ("folie  raisonnante  "). 

(2,)  Paranoia:  {a,')  Congenital  form  ;  (b,)  Acriuired  form. 

(ct,)  Paranoia  persecutoria  (primary  and  predominating  delusions 
as  to  injury  of  the  patient  by  others) :  (««,)  Typical  form  ;  (/3/3,) 
Paranoia  querulans. 

(/3,)  Paranoia  expansiva  (primary  and  predominating  delusions 
of  advanced  interests  of  the  personality) :  (aa,)  Paranoia  invent- 
toria  or  paranoia  ref ormatoria  ;  (/3/3, )  Paranoia  religiosa  ;  (77, ) 
Paranoia  erotica. 

(3,)  Periodical  insanity. 

(4,)  Insanity  proceeding  from  the  constitutional  neui'oses  :  («,) 
Neurasthenic  insanity  ;  (i,)  Epileptic  insanity;  (c,)  Hysterical 
insanity  ;  (d,)  Hypochondriacal  insanity. 

n. — Diseases  in  which  lesions  are  constantly  found — Brain 
diseases  with  predominating  mental  troubles — Organic  psychoses. 

(1,)  Delirium  acutum  (transudative  hypersemia  passing  into 
periencephalitis  diffusa  acuta). 

(2,)  Chronic  jjaralysis  or  dementia  paralytica  (periencephalo- 
meningitis diffusa  chronica). 

(3,)  Lues  cerebralis. 


10  DEFINITIONS   OF   INSANITY,    ETC. 

(4,)  Dementia  senilis  (primary  cerebral  atrophy). 

The  intoxications  constitute  a  transition  group  between  I.  and 
II : — (1,)  Alcoholismus  chronicus  ;  (2,)  Morphinismus. 

B. — States  of  ai-rested  psychical  development — Idiocy  (with 
eventual  bodily  degeneration — Cretinism)  :  (a,)  with  predomina- 
ting intellectual  defect — (congenital  imbecility  and  idiocy) ;  (b,) 
With  predominating  ethical  defect  (congenital  moral  imbecility 
and  idiocy). 


INDEX   OF   SYMPTOMS   SOMATIC,    ETC.  11 


CHAPTER   II. 

INDEX    OF    SYMPTOMS    SOMATIC    AND    PSYCHICAL, 

WITH  THE  MENTAL  DISEASES  IN  WHICH 

THEY  OCCUE. 

Abruptness  of  Outbreak. — In  the  attacks  of  periodical  insanity 
(usually). 

Absent-Mindedness. — Primary  mental  deterioration  (simple 
primary  dementia). 

Abulia. — Weakness  or  want  of  will.  In  simple  melancholia ; 
prodromal  period  of  mania  ;  prodromal  period  of  general  paralysis ; 
alcoholic  insanity ;  periodical  melancholia ;  forms  ending  in  general 
mental  enf eeblement ;  monomania  with  overwhelming  hallucina- 
tions and  delusion  (Spitzka).     In  chronic  hysterical  insanity. 

Activity,  Unusual  and  Useless.— In  the  prodromal  period  of 
general  paralysis. 

Acts,  Extraordinary. — In  moral  insanity. 

Acts,  Monotonous. — In  katatonic  insanity  (katatonia). 

Affective  Sensibility,  Perverted  or  Paralysed. — Natural  affection 
altered,  diminished,  or  lost.  In  general  paralysis  ;  chronic  alco- 
holic insanity  ;  puerperal  insanity  ;  lactational  insanity;  gestational 
insanity;  advanced  consecutive  insanity  (j;os/-febrile) ;  acute  mania  ; 
simple  melancholia ;  climacteric  insanity  ;  prodromal  period  of 
general  paralysis ;  second  stage  of  masturbational  insanity ;  diabetic 
insanity;  moral  insanity;  periodical  insanity  ;  pubescent  insanity 
(in  boys  at  beginning  of  attack) ;  chronic  mania. 

Ageustia. — Loss  of  the  sense  of  taste.  In  confirmed  general 
paralysis. 

Aggressiveness. — In  acute  mania  ;  chronic  mania  ;  some  cases  of 
agitated  terminal  dementia  ;  epileptic  insanity ;  traumatic  in- 
sanity .;  periodical  mania ;  monomania ;  sometimes  in  general 
paralysis. 

Agitation,  Excessive. — In  agitated  melancholia;  delirium  tremens; 
maniacal  form  of  saturnine  insanity  ;  acute  mania ;  in  some  cases  of 
depressive  general  paralysis  ;  in  acute  hysterical  insanity ;  constant 
in  expansive  syphilitic  insanity ;  some  cases  of  delirium  of  young 
children. 


12  INDEX   OF   SYMPTOMS   SOMATIC   AND    PSYCHICAL, 

Alcoholic  Excesses,  Tendency  to.— Toxic  insanity  (alcoholic 
form) ;  impulsive  insanity  (dipsomaniacal  form) ;  traumatic  in- 
sanity; periodical  insanity;  circular  insanity;  climacteric  insanity; 
general  paralysis  (prodromal  period  and  first  stage). 

Alternating  Exaltation  and  Depression,  with  or  without  Lucid 
InterYal. — Circular  insanity  (folic  circulaire,  folie  alternante,  and 
folie  a  double  forme) ;  occasionally  in  anaemic  insanity. 

Ambitious  Ideas.— Ambitious  delusional  insanity  (ambitious 
monomania) ;  religious  delusional  insanity  (religious  monomania, 
theomania)  ;  general  paralysis. 

Amenorrhoea. — In  prodromal  period  of  general  paralysis.  In 
most  forms  of  insanity  at  some  period. 

Amnesia,  marked  (apart  from  Unconsciousness). — Loss  of  memory. 

(1,)  For  recent  events.  In  prodromal  period  and  first  stage  of 
general  paralysis;  primary  mental  deterioration  (simple  primary 
dementia) ;  senile  insanity  ;  some  cases  of  chronic  mania  and 
terminal  dementia  ;  some  cases  of  organic  dementia  ;  some  cases 
of  chronic  alcoholic  insanity. 

(2,)  For  long  past  and  recent  events.  Advanced  terminal 
dementia  ;  advanced  chronic  alcoholic  insanity  ;  epileptic  insanity ; 
third  stage  of  general  paralysis ;  simple  depressive  syphilitic 
insanity  (advanced) ;  advanced  senile  insanity  ;  organic  dementia 
(some  cases)  ;  organic  melancholia  ;  some  cases  of  acute  mania  ; 
melancholy  foim  of  delirious  saturnine  insanity ;  advanced 
consecutive  insanity  (post-iehrile  form) ;  choreic  insanity  ;  insanity 
of  myxcedema  ;  most  severe  form  of  cataleptic  insanity  ;  delirium 
of  young  children;  sometimes  after  traumatisms. 

Anssmia. — In  anaemic  insanity  ;  early  chronic  hysterical 
insanity. 

Anaesthesia.— See  "  Cutaneous  Anaesthesia." 

Annoyance  at  Trifles. — In  incipient  climacteric  insanity. 

Anorexia.  —  Loss  of  appetite.  Alcoholic  pseudo  -  general 
paralysis.  Many  cases  of  melancholia  (See  "  Refusal  of 
Food). 

Anosmia. — Absence  or  loss  of  the  sense  of  smell.  In  some  cases 
of  general  paralysis  at  first,  and  in  all  at  last ;  some  cases  of 
organic  dementia  ;  some  cases  of  idiocy. 

Answers  Questions  Irrelevantly. — In  mania  ;  primary  mental 
deterioration  (simple  primary  dementia) ;  terminal  dementia 
(secondary  dementia). 

Anxiety — Alcoholic  insanity  ;  excited  melancholia  ;  hypochon- 
driacal melancholia  ;  puerperal  insanity. 

Apathy. — Anergic  stupor  (acute  dementia,  acute  primary 
dementia) ;  mild  gestational  insanity  (mild  insanity  of  pregnancy); 
chronic  alcoholic  insanity. 


WITH   THE   MENTAL   DISEASES   IN   WHICH   THEY   OCCUR.       13 

Aphasia. — Loss  of  speech :  here  used  in  a  general  and  comprehen- 
sive sense.    In  organic  dementia;  general  paralysis ;  senile  insanity. 
Apoplectiform    Attacks. — Insanity   from   coarse   brain   disease  ; 
often  precede  the  mental  troubles  of  syphilitic  pseudo-general 
paralysis  ;  general  paralysis  ;  chronic  alcoholic  insanity. 

Apparent  Unconsciousness. — Anergic  stupor  (acute  primary 
dementia) ;  stuporous  melancholia  (melancholia  attonita,  melan- 
colie  avec  stupeur) ;  acute  epileptic  insanity  during  the  attack  ; 
acute  delirium  (acute  delirious  mania,  delirium  grave) ;  epileptic 
and  general  paralytic  stupor  ;  melancholic  (most  common  form) 
true  rheumatic  insanity. 

Apprehensiveness.— In  melancholia.  Insanity  complicated  with 
heart  disease  ;  climacteric  insanity  ;  lactational  insanity  ;  gesta- 
tional insanity  ;  advanced  consecutive  insanity  ;  incipient  general 
^mralysis  (some  cases) ;  incipient  mania  (some  cases).  It  is  a 
frequent  prodroma  of  acute  delirium,  acute  mania,  and  general 
paralysis.  Folie  du  doute  ;  partial  emotional  aberration  ;  neuras- 
thenic insanity. 

Arcus  Senilis. — In  senile  insanity  ;  insanity  from  coarse  brain 
disease  (organic  dementia  and  organic  melancholia). 

Arteries  Atheromatous. — In  senile  insanity  ;  organic  dementia  ; 
organic  melancholia. 

Ataxia. — In  general  paralysis,  increasing  as  the  disease  pro- 
gresses, not  affected  by  shutting  eyes,  as  in  tabes  dorsalis  ;  in  the 
third  stage  of  general  paralysis — in  some  cases  the  patient  can 
neither  stand  nor  walk ;  in  severe  and  fatal  choreic  insanity  ;  in 
some  cases  of  acute  delirium  (acute  delirious  mania). 

Atony. — In  katatonia  (katatonic  insanity). 

Attention,  Power  of.  Defective. — In  primary  mental  deteriora- 
tion (simple  primary  dementia) ;  terminal  or  secondary  dementia  ; 
imbecility ;  general  paralj^sis  ;  mania  ;  melancholia  ;  organic 
dementia  ;  organic  melancholia  ;  senile  insanity  ;  chronic  epileptic 
insanity  ;  simple  depressive  syphilitic  insanity  ;  choreic  insanity ; 
lost  in  most  cases  of  delirium  of  young  children.  One  of  the 
prodromata  of  general  paralysis. 

Attitude  Immobile. — In  simple  melancholia. 

Attitude  Insinuating. — In  sexual  perversion  ;  erotomania. 

Attitude  Listless. — In  atonic  simple  melancholia. 

Attitude  Suggestive  of  Auditory  Hallucinations. — In  delusional 
insanity  (monomania),  especially  the  persecutory  and  ambitious 
forms  ;  melancholia  ;  mania  ;  alcoholic  insanity  ;  general  paralysis  ; 
puerperal  insanity  ;  consecutive  insanity. 

Attitude  Suggestive  of  Delusions  of  Grandeur. — In  general  para- 
lysis ;  ambitious  delusional  insanity  (ambitious  monomania) ; 
acute  mania. 


14  INDEX   OF   SYMPTOMS   SOMATIC   AND   PSYCHICAL, 

Automatic  Ideas  and  Words. — Ideas  arise  that  the  patient  knows 
to  be  false  ;  he  says  things  he  knows  to  be  wrong  but  "  cannot  help 
it."  In  impulsive  insanity ;  pubescent  insanity ;  climacteric 
insanity  ;  senile  insanity. 

Babbling  and  Chattering. — Excessive  and  incoherent  in  delirium 
tremens  ;  puerperal  mania  ;  consecutive  insanity. 

Back,  Weakness  in. — In  masturbational  insanity. 

Barometric  and  Seasonal  Conditions,  much  Influenced  by. — Perio- 
dical insanity  ;  epileptic  insanity. 

Bed,  Refusal  to  Leave. — Katatonia  (katatonic  insanity). 

Bedsores,  Liability  to. — In  third  stage  of  general  paralysis  ;  in 
insanity  from  coarse  brain  disease  on  paralysed  side. 

Biliousness. — In  adolescent  insanity. 

Blindness. — In  insanity  from  coarse  brain  disease  when  caused 
by  tumours  ;  in  some  cases  of  general  paralysis. 

Blood,  Alteration  of. — Coagulates  with  difficulty  or  not  at  all  in 
the  third  stage  of  general  paralysis,  and  in  other  cachectic  states  of 
the  insane  (Voisin) ;  haemoglobin  diminished  in  general  paralysis 
(Bevan  Lewis),  and  in  pubescent  and  adolescent  insanity,  with 
notable  stupor  ;  red  corpuscles  and  haemoglobin  diminished  in 
anaemic  insanity. 

Bodily  Functions,  Active  Disturbance  of  the. — In  acute  delirium 
(acute  delirious  mania") ;  melancholia ;  anergic  stupor  (acute 
dementia,  acute  primary  dementia,  stuporous  insanity) ;  katatonia  ; 
frenzy  (of  transitory  mania,  of  alcoholic  insanity,  or  of  melan- 
cholia) ;  initial  and  terminal  periods  of  general  paralysis  ;  senile 
dementia;  persecutory  delusional  insanity  (persecutory  mono- 
mania) (Spitzka). 

Bodily  Symmetry,  Want  of.— In  idiocy  ;  monomania  (delusional 
Insanity) ;  moral  imbecility. 

Brutishness. — In  chronic  alcoholic  insanity  ;  traumatic  insanity. 

Bulimia — Ravenous  appetite.     (See  "  Voracity.") 

Cachexia. — In  third  stage  of  general  paralysis  ;  often  very 
pronounced  in  syphilitic  pseudo-general  paralysis. 

Calculation,  Power  of,  DefectiYe.— Terminal  dementia  (secondary 
dementia) ;  primary  mental  deterioration  (simple  primary 
dementia) ;  imbecility  ;  general  paralysis  ;  organic  dementia  ; 
organic  melancholia  ;  senile  insanity. 

Catalepsy. — In  cataleptic  insanity ;  katatonia  (katatonic  in- 
sanity). 

Catamenia,  Disorders  of.— See  "Menstruation,"  " Amenorrhoea," 
etc. 

Cephalalgia — See  "  Headache." 

Change  of  Place,  Desire  for. — Expansive  intellectual  petit  mal. 

Character,  Change  of. — More  or  less  in  all  acquired  insanity. 


WITH   THE   MENTAL   DISEASES   IN   WHICH   THEY   OCCUR.       15 

Marked  in  prodromal  period  of  general  paralysis ;  m  simple 
depressive  syphilitic  insanity  ;  in  most  cases  of  incipient  rheu- 
matic insanity,  and  often  coincident  Avith  diminution  of  articular 
pains  ;  in  moral  insanity ;  in  these  forms  it  is  often  the  most 
prominent  and  sometimes  almost  the  only  symptom. 

Childishness,  in  Actions. — In  chronic  epileptic  insanity  (epileptic 
dementia) ;  idiocy  ;  imbecility. 

Choreic  Movements. — In  choreic  insanity  ;  sometimes  in  maniacal 
true  rheumatic  insanity. 

Coma,  or  Somnolence. — In  comatose  saturnine  insanity,  patient 
ansAvers  questions  but  falls  again  into  state  of  somnolence  or 
torpor ;  in  convulsive  form  of  saturnine  insanity  after  convulsive 
attack ;  at  termination  of  insanity  from  coarse  brain  disease  Avhen 
caused  by  tumour  ;  fatal  coma  is  a  frequent  termination  of  acute 
delirium  (acute  delirious  mania)  ;  sometimes  in  fatal  cases  of 
rheumatic  insanity  (comatose  form). 

Complexion,  Pale  and  Pasty. — In  mastm^bational  insanity. 

Concentration  of  the  Intellectual  Operations  round  one  Idea  or  set 
of  Ideas — In  folie  du  doute. 

Concentration  of  Thoughts  and  Feelings  on  Patient's  own  Health, 
Organs,  etc — In  hypochondriacal  melancholia  (hypochondriacal 
insanity). 

Conduct  and  Disposition,  Change  in. — One  of  the  first  symptoms 
in  almost  all  forms  of  insanity,  and  one  of  the  most  noticeable 
symptoms  in  incipient  general  paralysis,  in  simple  mania,  and 
in   simple  melancholia. 

Conduct,  Extraordinary. — in  moral  insanity. 

Confusion,  Feaiing  of. — In  traumatic  insanity. 

Confusion  of  Ideas. — In  katatonia ;  in  the  tumour  form  of 
organic  insanity  (insanity  from  coarse  brain  disease) ;  in  insanity 
of  cyanosis  from  bronchitis,  cardiac  disease,  and  asthma. 

Connect  Everything  with  Self,  Disposition  to. — In  hypochondri 
acal  melancholia. 

Consciousness  Abolished, — In  the  most  severe  form  of  cataleptic 
insanity  (Bra) ;  in  most  cases  of  delirium  of  yoiuig  children 
(Clouston). 

Consciousness  Confused. — In  primary  or  acute  confusional  in- 
sanity (Spitzka). 

Consciousness  Markedly  and  Demonstrably  Impaired.— In  epi- 
leptic insanity ;  transitory  frenzy  (transitory  or  ephemeral  mania) ; 
anergic  stupor  (acute  dementia,  acute  primary  dementia) ;  melan- 
cholic frenzy ;  alcoholic  frenzy  ;  acute  delirium  (acute  delirious 
mania,  delirium  grave) ;  frenzy  of  mania ;  frenzy  of  general 
paralysis  (paretic  dementia) ;  cataleptic  phases  of  katatonia 
(Spitzka). 


16  INDEX   OF   SYMPTOMS   SOMATIC   AND    PSYCHICAL, 

Consciousness,  Temporary  Losses  of. — In  the  prodromal  period 
of  general  paralysis. 

Constantly  making  the  same  Gesture. — In  idiocy  ;  acute  mania  ; 
chronic  mania ;  terminal  dementia ;  hysterical  insanity ;  some 
cases  of  each. 

Constipation.  —  In  idiocy  ;  melancholia  ;  organic  dementia  ; 
organic  melancholia  ;  climacteric  insanity  ;  prodromal  period  of 
general  paralysis  ;  chronic  hysterical  insanity  ;  obstinate  in  acute 
delirium  (acute  delirious  mania). 

Continuity,  Want  of,  in  Thought  and  Action. — In  incipient  mastiu'- 
bational  insanity. 

Controlled  and  OYcrpowered,  Sense  of  Being. — In  simple  melan- 
cholia. 

Convulsions.— (1,)  G-eneral  :  In  epileptic  insanity  ;  in  epileptic 
idiocy,  and  sometimes  in  other  forms  of  idiocy  and  in  some  cases 
of  imbecility ;  general  paralysis ;  syphilitic  insanity ;  organic 
■  dementia ;  katatonia ;  saturnine  insanity,  convulsive  saturnine 
seizures  resemble  epileptic  seizures  but  they  have  no  aura ; 
saturnine  pseudo-general  paralysis ;  some  cases  of  rheumatic 
insanity,  acute  and  sub-acute  ;  some  cases  of  traumatic  insanity ; 
accidentally  in  other  forms.  (2,)  Local  or  Jacksonian  :  In  general 
paralysis  ;  organic  dementia. 

Countenance  Expressionless. — In  apathetic  terminal  dementia  ; 
acute  delirium  (acute  delirious  mania) ;  confirmed  general 
paralysis  ;  anergic  stupor  (acute  dementia). 

Countenance,  Expressive  of  Distrust,  Indifference  and  Inertia,  In- 
quietude, or  Self-Effacement.— In  simple  melancholia. 

Countenance  Expressive  of  Wretchedness  and  Misery. — In  stupor- 
ous melancholia. 

Courage,  Failure  of. — In  climacteric  insanity ;  masturbational 
insanity. 

Cramps.— In  acute  delirium  (acute  delirious  mania) ;  katatonia. 

Cruelty. — In  congenital  moral  insanity  (moral  imbecility). 

Cursatory  Impulses — A  prodroma  of  the  attacks  in  acute  epilep- 
tic insanity. 

Cutaneous  Anaesthesia.  —  In  confirmed  general  paralysis ; 
hysterical  insanity  ;  organic  dementia  and  organic  melancholia 
(insanity  from  coarse  brain  disease) ;  alcoholic  pseudo-general 
paralysis  ;  traumatic  insanity. 

Dejection. — In  hypochondriacal  melancholia  (hypochondriacal 
insanity). 

Delirium. — In  acute  delirium ;  delirium  tremens  ;  delirium  of 
young  children  ;  furious  and  more  or  less  continuous  in  the 
maniacal  form  of  saturnine  insanity  ;  it  is  present  sometimes  in 
pubescent  insanity  ;  in  pneumonic  consecutive  insanity  ;  sometimes 


WITH   THE   MP:NTAL   DISEASES   IN   WHICH  THEY   OCCUR.       17 

in  insanity  from  coarse  brain  disease,  tumour  form ;  in  insanity 
of  cyanosis  from  bronchitis,  cardiac  disease,  and  asthma  ;  rarely 
in  uterine  or  amenorrhoeal  insanity. 

Delirium  with  Remissions. — In  insanity  of  Bright's  disease. 
Delusions. — Faulty  ideas  growing  out  of  a  perversion  or  weaken- 
ing of  the  logical  apparatus  (Spitzka). 

False  notions  and  ideas  (independently  of  false  inductions) 
which  have  no  immediate  reference  to  the  seiises  (Bucknill  anc 
Tuke). 

Legal  definition  of  a  delusion  : — A  faulty  belief,  out  of  which 
the  subject  cannot  be  reasoned  by  adequate  methods  for  the 
time  being. 

Delusions  are  divided  by  Spitzka  into  genuine  and  spurkms. 
{A,)  Genuine. — Those  created  by  the  patient  himself.    Genuine 
delusions  are  divided  into  : — 

(a,)  SydemaMsed. — Systematised  delusions  are  distinct  and  fixed 
and  present  circumstances  are  incorporated  in  a  pseudo-logical 
chain  (Spitzka).  The  patient  can  give  reasons  for  his  belief. 
Systematised  delusions  are  : — 

(a,)  Expaasii-c. — Expansive  systematised  delusions  may  be  : 
(1,)  Ambitious.  In  am])itious  delusional  insanity  (monomania 
of  pride  or  grandeur,  delusional  insanity  with  exalted  delusions) ; 
(2,)  Erotic.  Voluptuous  delusions  occur  more  frequently  in 
females  than  in  males.  In  erotic  delusional  insanity  (eroto- 
mania) ;  (-3,)  Eeligious.  In  religious  delusional  insanity  (religious 
monomania,  religious  mania,  theomania). 

(P,)  Depressive.  —  Depressive  systematised  delusions  may  be: 
(1,)  Hypochondriacal.  In  hypochondriacal  melancholia;  (2,) 
Persecutory.  In  persecutory  delusional  insanity  (monomania  of 
suspicion,  delusional  insanity  with  delusions  of  persecution). 

(6,)  Unsijstematised. — Unsystematised  delusions  are  vague  and 
changeable,  and  the  logical  power  of  the  patient  is  in  whole  or 
in  part,  in  abeyance  with  regard  to  them  (Spitzka).  They  are 
met  with  in  the  acute  insanities  and  chronic  cleteriorations 
(Spitzka).      They  may  be  : — 

(a,)  Expansive.  —  The  delusions  of  grandeiu:'  of  general 
paralysis  are  examples ;  they  are  due  to  destruction  of  the  logical 
associating  force  (Spitzka).  Expansive  unsystematised  delusions 
are  found  in  chronic  mania,  delusional  mania,  acute  mania, 
periodical  mania,  hysterical  insanity,  imbecility  ;  fragmentary  in 
agitated  terminal  dementia. 

(P,)  Depressive. — In  delusional  melancholia  (having  committed 
the  "unpardonable  sin,"  beijig  very  poor,  etc.);  religious 
melancholia  (eternal  damnation,  having  led  wicked  lives,  etc.) ; 
senile  melancholia  (delusions  of  suspicion  of  a  possible  nature, 

2 


18  INDEX   OF   SYMPTOMS    SOMATIC   AND    PSYCHICAL, 

such  as  stealing,  etc.,  by  members  of  the  household)  ;  senile 
dementia ;  secondary  or  terminal  dementia ;  periodical  melan- 
cholia;  lactational  insanity  (delusions  of  suspicion);  gestational 
insanity  (delusions  of  suspicion,  poison) ;  chronic  melancholia, 
included  by  Spitzka  in  chronic  confusional  insanity;  chronic 
alcoholic  insanity ;  katatonia ;  severe  climacteric  insanity  ; 
general  delusional  state  in  depressive  syphilitic  insanity  "with 
incoherence ;  some  cases  of  advanced  traumatic  insanity ;  some 
cases  of  imbecility ;  some  cases  of  true  melancholia  due  to 
emotional  disturbance  (Spitzka) ;  some  cases  of  general  paralj'sis 
(depressive  unsystematised  delusions  of  persecution) ;  of  poverty 
in  diabetic  insanity,  and  some  cases  of  depressive  general 
paralysis  ;  fragmentary  in  some  cases  of  agitated  dementia. 

(■y,)  Mingled. — ExpansiA'e  and  depressive  mingled;  in  primary 
or  acute  confusional  insanity  (delusions  of  identity  are  very 
common  in  this  disorder) ;  senile  dementia ;  ejDileptic  insanity  ; 
katatonia;  pubescent  insanity  (insanity  of  pubescence)  (Spitzka); 
as  to  surrounding  persons  in  insanity  of  Bright's  disease. 

{B,)  Spupjous. — Spurious  delusions  are  those  adopted  from 
others  (Spitzka).  These  delusions  are  very  frequently  persecutory 
(unseen  agency,  the  telephone,  electricity,  etc.).  In  folie  a 
deux. 

For  examples  illustrating  the  difference  between  a  delusion,  a 
hallucination,  and  an  illusion,  see  "  Illusions." 

Depression. — In  melancholia  ;  puerperal  melancholia  ;  lactational 
insanity  ;  gestational  insanity  ;  senile  melancholia ;  periodical 
melancholia  ;  climacteric  insanity  ;  most  cases  of  sub-acute  or 
true  rheumatic  insanity  ;  anaemic  insanity,  occasionally  alternating 
AAdth  an  acutely  maniacal  condition  ;  phthisical  insanity ;  depres- 
sive connrmecl  general  jmralysis  (not  common) ;  mild  cataleptic 
insanity ;  insanity  from  deprivation  of  the  senses ;  insanity  of 
oxaluria  and  phosphaturia  ;  insanity  from  abdominal  disorders, 
especially  from  hepatic  derangements  ;  diabetic  insanity  ;  post- 
connubial  insanity ;  two  thirds  of  cases  of  uterine  insanity  ; 
chloral  insanity ;  katatonia ;  great  in  pellagrous  insanity ; 
pubescent  insanit}",  in  early  stages  and  afterwards  alternat- 
ing Avith  delirium,  etc. ;  sometimes  at  commencement  of 
adolescent  insanity  ;  commencement  of  organic  dementia ;  com- 
mencing saturnine  insanity ;  traumatic  insanity,  at  first ;  some- 
times in  incipient  general  paralysis ;  early  puerperal  mania  : 
often  prodromal  of  general  paralysis  ;  a  frec[uent  prodroma  of 
acute  mania  ;  sometimes  prodromal  of  the  outbursts  of  periodical 
mania  ;  at  end  of  acute  delirium  ;  advanced  consecutive  insanity ; 
sometimes  after  acute  symptoms  of  acute  mania  pass  ofi" ;  at  end 
of  puerperal  mania  sometinies  ;  in  some  cases  of  syphilitic  de- 


WITH   THE  MENTAL   DISEASES   IN   WHICH   THEY   OCCUR.       19 

pression  with  incoherence ;  some  cases  of  hysterical  insanity  ; 
some  cases  of  choreic  insanity ;  some  cases  of  insanity  of  myxoe- 
dema  ;  some  cases  of  delirium  of  young  children. 

Despondency,  Intense  Religious. — In  religious  melancholia 

DestructiYeness. — In  destructive  mania  (a  form  of  impulsive 
insanity) ;  acute  mania ;  sometimes  in  chronic  mania ;  agitated 
terminal  dementia ;  epileptic  insanity  during  the  paroxysms ; 
persecutoiy  delusional  insanity  (monomania  of  suspicion)  at 
times ;  maniacal  cases  of  rheumatic  insanity ;  insanity  with 
exophthalmic  goitre. 

Diarrhoea. — Succeeds  constipation  near  the  termination  of 
acute  delirium  (acute  delirious  mania) ;  in  advanced  general 
paralysis. 

Diminutives,  Tendency  to  use. — In  katatonia  (katatonic  insanity). 

Dirty  in  Habits:  (a,)  From  InaUeidion,  Indifference  or  Ferverse- 
ness. — In  terminal  or  secondary  dementia,  esj)ecially  the  apathetic 
form ;  third  stage  of  general  paralysis ;  idiocy ;  puerperal 
insanity ;  acute  mania ;  chronic  mania ;  insanity  ^vith  exoph- 
thalmic goitre.  (6,)  From  Unconsciousness. — In  anergic  stupor 
(acute  primary  dementia) ;  during  the  paroxysms  of  epileptic 
insanity,  (c,)  From  Paralysis  of  Sjjhincter. — In  organic  dementia  ; 
third  stage  of  general  paralysis ;  saturnine  pseudo-general 
paralysis. 

Discontentedness. — In  some  cases  of  simple  melancholia. 

Disposition,  Change  in — See  "Conduct  and  Disposition,  Change 
in." 

Distortion  of  Surrounding  Objects  and  Persons. — One  of  the 
prodrom.ata  of  acute  delirium  (acute  delirious  mania). 

Dread,  Unfounded. — Especially  on  awaking  from  sleep  early  in 
the  morning  in  podagrous  or  gouty  insanity. 

Dreaminess. — In  incipient  folic  du  doute. 

Dress  and  Undress,  Inability  to.— In  acute  delirium  (acute 
delirious  '  mania) ;  anergic  stupor  (acute  primary  dementia) ; 
second  and  third  stages  of  general  paralysis  ;  epileptic  insanity 
during  the  paroxysmal  excitement ;  organic  dementia ;  organic 
melancholia  ;  stuporous  melancholia. 

Dressing  Fantastically.— In  feigned  insanity ;  acute  mania ; 
chronic  mania;  periodical  mania  ;  maniacal  phase  of  folic  circulaire. 

Dressing  Negligently. — In  melancholia. 

Dress  Suggestive  of  Exalted  Ideas. — In  ambitious  delusional 
insanity  (monomania  of  pride  or  grandeur) ;  general  paralysis. 

Drink,  Intense  Craving  for. — In  alcoholic  insanity ;  dipsomania, 
periodically ;  often  the  most  prominent,  and  sometimes  the  only, 
symptom  of  climacteric  insanity ;  periodical  mania  ;  folic 
circulaire  ;  many  cases  of  traumatic  insanity. 


20  INDEX   OF   SYMPTOMS   SOMATIC   AND   PSYCHICAL, 

Drowsiness. — In  cretinism;  after  meals  in  incipient  general 
paralysis. 

Dulness  and  Indifference. — In  choreic  insanity. 
Dynamometric  Indications — See  "  Grip  Feeble." 
Dysmenorrhoea  and  Irregular  Menstruation. — In  incipient  chronic 
hysterical  insanity  and  the  prodromal  j)eriod  of  the  same  disease. 
Dyspepsia. — One    of    the    prodromata    of    chronic    hysterical 
insanity  ;  in  primary  mental  deterioration  ;  prodromal  of  general 
paralysis.     (See  "  Gastric  Embarrassment.") 

Echolalia. — "The  thoughtless  repetition  of  Avorcls  and  phrases' 
spoken  by  others,  the  subject  not  associating  any  mental  con- 
ception with  them  "  (Spitzka) ;  in  imbecility,  insanity  of  pubei'ty, 
dementia  (Spitzka). 

Egotism,  Increased. — Ambitious  delusional  insanity ;  general  par- 
alysis, often  very  much  in  the  prodromal  period  and  first  stage  ; 
pubescent  insanity ;  adolescent  insanitj^ ;  early  masturbational 
insanity;  senile  dementia  ;  senile  melancholia  ;  chronic  hysterical 
insanity ;  partial  exaltation. 

Electric  Sensibility,  Abolished  or  Altered. — In  confirmed  general 
paralysis. 

Emaciation. — In  acute  delirium  ;  acute  mania ;  acute  melan- 
cholia ;  epileptic  insanitj^  during  paroxysmal  excitement ;  mastur- 
bational insanity  ;  phthisical  insanity  ;  climacteric  insanity  ; 
chronic  hysterical  insanity  ;  melancholy  phase  of  folie  circulaire  ; 
insanity  from  coarse  brain  disease ;  diabetic  insanity ;  early 
lactational  insanity  ;  some  cases  of  general  paralysis. 

Emotional. — In  organic  dementia  ;  advanced  general  paralysis. 
Emotional   Disturbance    (marked). — Ma}^    be    present    with    or 
without  intellectual  motive  : — 

(A,)  Without  Intellectual  Motive. — May  be  angry, 
expansive,  or  depressed  : — 

(a,)  Angry. — (1,)  Simply:  In  maniacal  furor;  furor  of  general 
paralysis  (paretic  dementia) ;  periodical  mania  ;  (2,)  Angry  and 
Treacherous  :  In  ej)ileptic,  alcoholic,  and  general  paralytic  furor  ;  (3,) 
Angry  and  Anxious:  In  melancholic  frenzy  (paroxysms  of  agitated 
melancholia) ;  transitory  frenzy  (transitory  mania) ;  katatonia. 

(h,)  Eo:2xinsive,  Good-humoured,  or  Fleasnrahle.- — In  simple  mania ; 
periodical  mania  ;  general  paralysis  (pai'etic  dementia). 

(c,)  Depressed,  Sad  and  Anxious. — In  simple  melancholia ; 
periodical  melancholia ;  alcoholic  insanity ;  epileptic  insanity; 
early  general  paralysis  ;  katatonia  ;  insanity  of  puberty. 

(B,)  With  Intellectual  Motive. — May  be  angry  and  expan- 
sive, or  depressed : — 

(a,)  Angry  and  Expansive, — In  episodical  delirium  of  mono- 
mania (delusional  insanity). 


WITH  THE   MENTAL   DISEASES    IN   WHICH   THEY   OCCUR.       21 

(b,)  Depressed. — In  prodromal  period  of  mania ;  monomania 
with  depression  ;  primary  mental  deterioration  (Spitzka).  (See 
"  Depression,"  "  Exaltation.") 

Emotions,  Blunted. — In  sub-lucid  intervals  of  long-standing 
periodical  insanity. 

Energy,  Diminished. — In  sub-lucid  intervals  of  long-standing 
periodical  insanity. 

Enjoyment  of  Life  much  Diminished  or  Lost. — In  organic  melan- 
cholia ;  simple  melancholia ;  prodromal  period  of  erotic  and 
religious  delusional  insanity. 

Epileptic  Seizures. — In  epileptic  insanity ;  early  general  paralysis ; 
insanity  from  absinthe  ;  alcoholic  insanity  ;  saturnine  pseudo-gen- 
eral paralysis  ;  cerebral  sj^philis ;  some  cases  of  traumatic  insanity. 
Epileptiform  Attacks. — In  general  paralysis  ;  organic  insanity 
(insanity  from  coarse  brain  disease) ;  senile  dementia ;  alcoholic 
insanity  ;  alcoholic  pseudo-general  paralysis ;  precede  comatose 
saturnine  insanity  ;  often  precede  psychical  troubles  in  syphilitic 
pseudo-general  paralysis ;  in  many  cases  of  katatonia. 

Erotic  Ideas  or  Tendency. — In  erotomania  (erotic  delusional 
insanity) ;  ovarian  or  old  maid's  insanity,  occurring  in  single 
females  aged  35  to  43  ;  in  puerperal  insanity  ;  early  general  par- 
alysis ;  mania  ;  epileptic  insanity ;  opium  or  morphia  insanity ;  often 
in  consecutive  insanity  (post-febrile) ;  prodromal  of  religious 
delusional  insanity,  also  a  symptom  of  the  fully  developed  disease  ; 
some  cases  of  chronic  hysterical  insanity. 

Exacerbations  at  Menstrual  Periods. — In  chronic  hysterical 
insanity ;  periodical  insanity. 

Exaggeration,  Ideas  of. — In  confirmed  general  paralysis  (expan- 
sive or  most  common  form). 

Exaggeration  of  Trifles —  In  incipient  delusional  insanity 
(incipient  monomania). 

Exaggeration,  Proneness  to. — In  expansive  syphilitic  insanity. 
Exaltation. — Ambitious  delusional  insanity  (monomania  of  pride 
or  grandeur) ;  partial  exaltation  or  amenomania  ;  theomania  ; 
erotomania  ;  most  cases  of  general  paralysis  ;  mania  ;  periodical 
mania  ;  maniacal  phase  of  folie  circulaire ;  adolescent  insanity  ; 
third  or  maniacal  stage  of  masturbational  insanity  ;  expansive 
syphilitic  insanity ;  about  one-third  of  the  cases  of  uterine  insanity  ; 
occasionally  in  anaemic  insanity  alternating  with  a  melancholic 
condition. 

Exaltation  and  Depression  Alternating  Momentarily. — In  acute 
rheumatic  insanity. 

Excess  in  Eating  (Bulimia)  and  Drinking. — ^^One  of  the  prodromata 
of  general  paralysis.     (See  "  Voracity.") 

Excess,  Sexual. — One  of  the  prodromata  of  general  paralysis. 


22  INDEX   OF   SYMPTOMS   SOMATIC   AND   PSYCHICAL, 

Excitement,  Motor  and  Mental. — May  be  constant,  occasional,  or 
periodical:  (ft,)  Constant. — In  acute  delirium;  acute  mania; 
agitated  melancholia ;  delirium  tremens ;  puerperal  mania ; 
insanity  with  exophthalmic  goitre ;  severe  choreic  insanity ; 
{h,)  Occasional. — In  delusional  insanity  (monomania);  epileptic 
insanity;  general  paralysis;  phthisical  insanity;  depressive  syphil- 
itic insanity,  A^'ith  incoherence  ;  idiocy  ;  mania,  simple,  delusional, 
and  chronic ;  terminal  or  secondary  dementia ;  katatonia. 
{c,)  Periodical. — In  periodical  mania ;  folie  circulaire  ;  followed  by 
prostration  in  epilepsie  lar^-ee. 

Excretions,  Deficient. — In  stuporous  melancholia. 

Exertion,  Mental  and  Bodily,  Feeling  of  Incapacity  for. — In  trau- 
matic insanity. 

Exhaustion,  Nervous. — In  acute  delirium ;  severe  delirium 
tremens  ;  primary  mental  deterioration  ;  consecutive  insanity. 

Extravagance  fas  to  Expenditure,  etc.). — In  moral  insanitv. 

Extremities  Cold  and  Bluish. — Often  in  idiocy. 

Eye,  Averted. — In  masturbational  insanity. 

Eyes,  Downcast. — In  simple  melancholia. 

Eyes,  Fixed. — In  melancholic  true  rheumatic  insanity. 

Eyes,  Glistening.— In  acute  mania. 

Eyes,  Hollow. — In  melancholic  true  rheumatic  insanity. 

Eyes,  Injected. — In  acute  mania ;  acute  delirium  ;  prodromal 
period  of  general  paralysis. 

Face,  Flushed.— In  acute  mania. 

Face,  Haggard. — In  masturbational  insanity. 

Face,  Sudden  Redness  of. — In  prodromal  period  of  general 
paralysis. 

Facial  Circulation  Defective. — In  general  paralysis. 

Facial  Expression,  Denoting  Terror. — In  delirium  tremens ;  agitated 
or  anxious  melancholia ;  some  cases  of  stuporous  melancholia. 

Facial  Expression,  Dull  and  Apathetic. — In  primary  mental 
deterioration  (simple  primary  dementia) ;  organic  dementia. 

Facial  Expression,  Dull  and  Self-absorbed. — In  puerperal  mania 
at  commencement. 

Facial  Expression,  Gloomy. — In  melancholia. 

Facial  Expression,  Indicating  Elation. — In  ambitious  delusional 
insanity  (monomania  of  pride) ;  general  paralysis ;  hysterical 
mania  ;  partial  exaltation  or  amenomania. 

Facial  Expression,  Vacant. — In  anergic  stupor  (acute  dementia, 
acute  primary  dementia) ;  apathetic  terminal  dementia  ;  long- 
continual  agitated  terminal  dementia,  esi^ecially  when  the  patient 
is  asked  a  question ;  idiocy ;  primary  mental  deterioration ; 
general  paralysis ;  some  cases  of  stuporous  melancholia.  (See 
"  Coimtenance,  Expressive  of,  etc.") 


WITH   THE   MENTAL   DISEASES    IX   \yHICH   THEY   OCCUR.       23 

Facial  Muscles,  Chorea-like  MoYements  of. — In  katatonia. 

False  and  Malevolent  Assertions,  Making. — In  moral  insanity. 

Fatigued,  Easily. — In  hypochondriacal  melancholia ;  one  of  the 
prodi'omata  of  general  paralysis. 

Fatuity. — In  adA^anced  terminal  dementia  ;  epileptic  dementia  ; 
advanced  senile  dementia  ;  alcoholic  dementia  ;  advanced  primary 
mental  deterioration  (simple  primary  dementia). 

Features  Contracted.— In  stuporons  melancholia ;  true  rheu- 
matic insanity. 

Fed  Forcibly,  Requiring  to  be.— In  some  cases  of  melancholia  ; 
some  cases  of  persecutory  monomania ;  some  cases  of  puerperal 
insanity  ;  some  cases  of  terminal  dementia. 

FeYerishness. — See  "  Temperature.'" 

Fickleness. — In  simple  mania. 

Fly  or  Hide,  Tendency  to.— In  some  cases  of  persecutory 
delusional  insanity  (persecutory  monomania)  in  the  early  stages 
])efore  the  delusions  have  become  systematised  and  fixed. 

Food,  Refusal  of.— See  "  Eefusal  of  Food." 

Force,  Want  of,  in  Thought  and  Action.— In  incipient  mastur- 
bational  insanity. 

Forgetfulness. — In  primary  mental  deterioration  (simple  primary 
dementia) ;  a  prodroma  of  general  paralysis ;  in  organic  demen- 
tia ;  simple  depressive  syphilitic  insanity. 

Formication. — Prodromal  of  an  attack  of  acute  epileptic  in- 
sanity ;  i^rodromal  of  general  paralysis. 

Gaining  Flesh. — In  mania  becoming  chronic,  the  mental  symp- 
toms not  improving ;  in  some  cases  of  general  paralysis  and  in  the 
remissions  of  that  disease ;  terminal  or  secondary  dementia ; 
during  convalescence  from  mania,  melancholia,  and  other  mental 
diseases. 

Gait,  Unsteady,  Staggering,  or  Halting.— In  confirmed  general 
paralj^sis  ;  organic  dementia  ;  organic  melancholia ;  acute  delirium ; 
alcoholic  insanity  ;  syphilitic  insanity  ;  idiocy. 

Gastric  Embarrassment.— In  delirium  tremens  ;  alcoholic  pseudo- 
general  paralysis  ;  insanity  from  opium  ;  primary  mental  deteri- 
oration ;  prodromal  of  general  paralysis.     (See  "  Dyspepsia.") 

Giddiness  (Yertigo). — In  epileptic  insanitj^ ;  organic  dementia  ; 
organic  melancholia  ;  traumatic  insanity ;  a  prodroma  of  general 
paralysis,  mania,  melancholia,  and  lactational  insanity ;  in  incipient 
acute  rheumatic  insanity ;  some  cases  of  senile  dementia ;  some- 
times in  commencing  saturnine  insanity ;  pneumonic  consecutive 
insanity ;  sometimes  precedes  an  attack  of  periodical  mania. 

Giving  Away  Property. — In  general  paralysis  ;  acute  mania  ; 
ambitious  delusional  insanity  (monomania  of  pride  or  ambition) ; 
some  cases  of  simple  mania. 


24  INDEX   OF   SYMPTOMS   SOMATIC   AND    PSYCHICAL, 

Glance,  Unusually  Yivacious. — In  prodromal  period  of  general 
pai-alysis. 

Gloominess. — In  epilepsy ;  in  folie  du  doute  at  the  commence- 
ment ;  melancholia. 

Grinding  Teeth. — In  confirmed  general  paralysis  ;  acute  delirious 
mania  (acute  delirium,  delirium  grave). 

Grip,   Feeble. — The  grip  (as  tested  Ly   the  dynamometer)   of 
almost  all  insane  persons,  except  sufterers  from  early  epileptic 
insanity,  is  weaker  than  that  of  sane  persons  of  somewhat  similar 
age  and  physique.    It  is  very  weak  in  general  paralysis  and  melan- 
cholia, and  in  organic  dementia  the  hand  of  the  apparently  sound 
side    is  much  less    powerful   than   that   of    a   healthy    person : 
(a,)  Of  both  Hands  equalli/. — In  general  paralysis;  melancholia; 
(b,)  Of  one  Hand  more  than  the  other. — In  organic  dementia;  organic 
melancholia  ;  some  cases  of  general  paralysis. 
Groaning. — In  melancholia  ;  senile  melancholia. 
Gustatory  Hallucinations. — See  "Hallucinations." 
Gyratory  Impulses. — Prodromal  of  acute  epileptic  insanity. 
Habits,  Change  of. — In  all  forms  of  acquired  insanity.     Prom- 
inent in  simple  mania  and  moral  insanity ;  prodromal  of  mania, 
melancholia,  and  general  paralysis  in  many  cases. 

Haeraatoma  Auris  or  Othsematoma. — A  swelling  of  the  external 
ear  containing  blood.  Sanguineous  or  serous  cyst  of  auricle  (U. 
Pritchard}.  These  othsematomata  are  not  peculiar  to  the  insane,  and 
are  not  necessarily  indicative  of  incurability,  l)ut  they  occur  much 
more  frequently  in  chronic  incurable  cases  of  insanity  than  in  recent 
and  curable  ones,  and  are  rare  in  the  sane  compared  with  the  insane. 
Opinions  vary  as  to  the  part  played  I)}''  violence  in  the 
causation  of  ha^matoma  auris. 

In  general  paralysis ;  mania,  especially  chronic  mania ;  melan- 
cholia ;  organic  dementia ;  terminal  or  secondary  dementia ; 
epileptic  insanity. 

Haemorrhages,  Mucous. — Liable  to  occur  towards  the  termin- 
ation of  general  paralysis. 

Hallucinations. — A  hallucination  is  a  perception  without  an 
object  (Ball).  Hallucinations  are  most  frequently  met  with  in 
monomania  (delusional  insanity)  and  melancholia,  but  are  not 
uncommon  in  mania  (Bucknill  &  Tuke).  For  other  forms  in 
which  they  occiu-  see  the  hallucinations  of  the  several  senses, 
vision,  hearing,  etc.     They  may  be  simple  or  componnd : — 

(A,)  Simple. — Simple  hallucinations  are  those  affecting  only 
one  sense.  The  hallucinations  are  painful  and  terrifying  in 
choreic  insanity  and  true  rheumatic  insanity.  They  are  of  a 
depressive  character  in  katatonia.  The  hallucinations  and  delu- 
sions are  mixed  and  contradictory,  and  the  former  often  prepon- 


WITH   THE   MENTAL   DISEASES    IN   WHICH   THEY   OCCUR.       20 

derate  from  the  first  in  primary  or  acute  confusional  insanity. 
Hallucinations  may  be  auditory,  visual,  gustatory,  olfactory, 
tactual  or  cutaneous,  sexual,  or  visceral  or  internal. 

(1,)  Auditory. — Hallucinations  of  hearing  are  more  frequent 
than  those  of  any  of  the  other  senses  (Bucknill  &  Tuke,  Savage, 
Bra).  They  may  range  from  mere  buzzings,  thumpings,  and 
ringing  of  bells  to  "  voices."  Auditory  hallucinations  are  very 
common  in  delusional  insanity,  especially  the  persecutory  and 
ambitious  forms ;  according  to  Griesinger  they  are  specially  frequent 
in  connection  with  diseases  of  the  abdomen  and  genital  organs  ;  in- 
sanity from  abdominal  disorders  (disease  of  bladder,  etc.) ;  mania, 
acute,  chronic,  and  delusional ;  melancholia,  acute  and  delusional  : 
delirium  tremens  ;  chronic  alcoholic  insanity  ;  puerperal  insanity  ;. 
climacteric  insanity ;  general  paralysis  ;  early  stage  of  terminal 
dementia  ;  post-febrile  consecutive  insanity ;  pneumonic  consec- 
utive insanity ;  hummings,  whistlings,  sound  of  bells  prodromal 
of  general  paralysis  ;  choreic  insanity  ;  of  a  disagreeable  character 
in  melancholic  uterine  insanity ;  insanity  from  deprivation  of 
senses  ;  insanity  of  myxoedema  ;  lactational  insanity. 

(2,)  Visual. — Next  in  frequency  to  those  of  hearing.  Vary 
from  blurs,  clouds,  or  haloes,  to  flashes  of  light,  bright  colour 
perceptions,  faces  and  figures  of  persons  at  some  occupation, 
animals,  etc.  (Spitzka).  Especially  frequent  in  acute  delirium 
and  delirium  tremens ;  in  the  latter  disease  they  are  painful, 
mobile,  nocturnal,  in  the  former  terrifying ;  occur  also  in  alcoholic 
pseudo-general  paralysis ;  monomania,  especially  the  religious 
form  ;  chronic  alcoholic  insanity,  painful,  mobile,  nocturnal ;  early 
stages  of  terminal  dementia  ;  acute  and  chronic  mania  ;  puerperal 
insanity ;  lactational  insanity ;  general  paralysis ;  painful  and 
terrifying  in  choreic  insanity,  acute  and  subacute  rheumatic 
insanity,  and  in  melancholic  form  of  delirious  saturnine  insanity  : 
worse  at  night  in  insanity  of  cyanosis  from  bronchitis,  etc. ;  occur 
in  pneumonic  consecutive  insanity ;  saturnine  pseudo-general 
paralysis  ;  sometimes  in  post-febrile  consecutive  insanity ;  insanity 
of  myxoedema;  insanity  of  abdominal  disorders  ;  frightful  in  some 
cases  of  delirium  of  young  children  ;  they  occixr  in  epileptic 
insanity  and  hysterical  insanity. 

(3,)  Q'ushdonj. — Hallucinations  of  taste,  though  much  less  often 
met  with  than  those  of  sight,  come  next  in  frequency.  They  are 
most  frec[uently  observed  in  persecutory  delusional  insanity 
(suspicions  of  poisoning),  religious  delusional  insanity,  hypochon- 
driacal melancholia,  delusional  melancholia,  chronic  alcoholic 
insanity ;  they  occur  in  general  paralysis,  insanity  of  puberty 
(where  they  point  to  masturbation  according  to  Spitzka),  acute 
mania,  acute  melancholia,  and  in  conditions  of  weak  mindedness, 


26  INDEX   OF   SYMPTOMS    SOMATIC   AND    PSYCHICAL, 

ovarian  disease,  and  phthisis  (Savage) ;  occur  in  puerperal  mania 
and  choreic  insanity  ;  acute  epileptic  insanitj^ 

(4,)  Olf actor )j. — Hallucinations  of  smell  appear  chief!)'-  to  belong 
to  early  stages  of  insanity  (Griesinger).  Like  those  of  taste  they 
rarely  occur  uncomplicated  with  those  of  other  senses  (Bucknill 
&  Tuke).  They  usually  coexist  mth  those  of  taste  (Spitzka). 
They  are  common  in  hypochondriacal  melancholia,  and  in  general 
parah'-sis,  and  are  almost  characteristic  of  masturlDatory  insanity 
(Krafft-Ebing,  Spitzka).  They  are  occasionally  pleasant  in  the 
excitement  of  mania  and  general  paralysis  and  in  religious 
monomania,  but  in  many  cases  of  mental  depression  especially 
those  associated  Avith  ovarian  and  uterine  troubles  the  smells  are 
of  an  unpleasant  kind  (Savage).  Unpleasant  in  early  puerperal 
insanity ;  disagreeable  in  chronic  alcoholic  insanity ;  occiu"  in 
choreic  insanity  ;  lactational  insanity  ;  acute  epileptic  insanity. 

(5,)  Tactual,  Tactile,  Cutaneous,  or  of  Common  Sensibiliti/. — 
Patients  complain  of  feeling  electric  shocks,  of  being  magnetised, 
of  having  chemical  substances  applied  to  the  skin,  of  vermin 
crawling  on  the  skin,  etc.  In  climacteric  insanity  (Savage). 
According  to  Savage  ("Insanity,"  page  74),  "Where  we  have 
ovarian  troubles  we  may  expect  to  find  hallucinations  of  smell 
and  touch."  Occur  occasionally  in  insanity  of  puberty,  and  in 
melancholia ;  also  in  persecutory  delusional  insanity ;  chronic 
alcoholic  insanity  ;  delirium  tremens  ;  choreic  insanit3^ 

(6,)  Sexual  (Bra). — In  erotomania;  puerperal  insanity;  general 
paralysis  ;  chronic  alcoholic  insanity. 

(7,)  Visceral  or  Internal. — Difficult  or  impossible  to  distinguish 
from  Adsceral  or  internal  illusions  (q.  v.). 

(B,)  Compound  Hallucinations. — Hallucinations  affecting 
two  or  more  senses.  Hallucinations  of  several  senses  are  more 
common  than  those  of  one  ;  sometimes,  though  rarely,  all  the 
senses  ai^e  involved  (Bucknill  &  Tuke).  Lactational  insanity, 
smell,  sight,  and  hearing;  acute  epileptic  insanity,  sweet  tastes 
and  strong  odom's  (Bra)  ;  mania ;  alcoholic  insanity ;  general 
paralysis  ;  masturl^ational  insanity  ;  puerperal  insanity  ;  phthisical 
insanity ;  monomania  ;  choreic  insanity  ;  melancholia. 

For  examples  illustrating  difference  between  "Delusions," 
"Hallucinations,"  and  "Illusions,"  see  "Illusions." 

Happiness,  Feeling  of. — In  partial  exaltation  ;  confirmed  general 
paralysis. 

Headache. — Intense  in  organic  dementia  from  tumom^s ;  severe 
in  puerperal  mania  ;  occipital  in .  katatonia  (Kahlbaum) ;  with 
uneasy  sensations  at  top  of  head  in  early  lactational  insanity  ;  at 
beginning  and  end  of  primary  confusional  insanity  ;  pulsatory  or 
giinding    in    traumatic    insanity ;    frontal    in   early   rheumatic 


WITH   THE   MENTAL   DISEASES   IN   WHICH   THEY   OCCUR.       2T 

insanity  (often) ;  commencing  saturnine  insanity ;  prodromal  of 
general  paralysis,  acute  delirium,  acute  mania,  melancholia,  apyretic 
delirium  tremens,  and  sometimes  periodical  mania. 

Head,  Flashes  of  Heat  to.— Prodromal  of  general  paralysis.  In 
neurasthenia. 

Head,  Pains  in. — Masturbational  insanity. 

Head  Proportionately  Large. — In  hydrocephalic  idiocy ;  cretinism. 

Head,  Sensation  of  Electric  Currents  in. — Piodromal  of  general 
paralysis. 

Head,  Sensation  of  Fulness  or  Bursting  of. — In  acute  mania. 

Head,  Sensation  of  Pressure  or  Fulness  in. — In  primary  mental 
deterioration.     Neurasthenia  and  neurasthenic  insanity. 

Head  Very  Small. — In  microcephalic  idiocy. 

Hearing  Impaired. — In  insanity  from  myxoedema. 

Hearing  Voices — 8ee  "  Hallucinations,"  Auditory. 

Heart,  Palpitation  of. — In  masturbational  insanity. 

Heat  Sense,  Abolished  or  Altered. — In  confirmed  general  paralysis.. 

Hemianaesthesia. — In  organic  insanity ;  hysterical  insanity ; 
general  paralysis. 

Hemiplegia. — See  "  Paralysis." 

Homicidal  Impulse.— See  "  Kill,  Impulse  to,"  under  "  Impulsive 
Acts." 

Hopelessness. — In  climacteric  insanity. 

Hyperacousia. — In  first  stage  of  general  paralysis  ;  in  acute 
mania  at  commencement ;  precursory  of  apyretic  delirium  tremens^ 

Hyperaesthesia  (Cutaneous) — Temporary  in  early  general  paraly- 
sis ;  hysterical  insanity ;  some  cases  of  senile  dementia ;  precursory 
of  apyretic  delirium  tremens  and  of  alcoholic  pseudo-general  par- 
alysis ;  traumatic  insanity. 

Hyperbulia. — Wilfulness.  In  mania ;  general  paralysis  ;  jDeriodi- 
cal  insanity ;  expansive  monomania  (ambitious  delusional  insanity). 

Hypochondriasis. — Prodromal  of  general  paralysis ;  occurs  in 
climacteric  insanity  ;  chronic  hysterical  insanity  ;  during  lucid 
intervals  of  traumatic  insanity  ;  second  stage  of  masturbational 
insanity  ;  insanity  of  oxaluria  and  phosphaturia  ;  precedes  hypo- 
chondriacal melancholia.  In  neurasthenia  and  neurasthenic 
insanity. 

Hysterical. — In  sub-lucid  intervals  of  periodical  insanity. 

Hysterical  Convulsions. — In  many  cases  of  katatonia  (Spitzka). 

Hysterical  or  Hystero-Epileptic  Fits.—Occurring  in  middle-aged 
men  suggest  general  paralysis  (Savage) ;  are  often  replaced  by  the 
maniacal  attacks  of  acute  hysterical  insanity. 

Ideas,  Mobile  and  Futile. — In  choreic  insanity. 

Ideas,  Multiple,  Mobile,  Absurd,  and  Contradictory. — In  the  first 
stage  of  confirmed  general  paralysis. 


28  INDEX   OF   SYMPTOMS   SOiLA.TIC   AND   PSYCHICAL, 

Ideas,  Paucity  of. — In  melancholia. 

Identity,  Mistakes  of. — In  delusional  insanity  ;  senile  insanity  ; 
puerperal  insanity;  lactational  insanity  ;  mania;  general  paralysis  ; 
agitated  terminal  dementia ;  chronic  confusional  insanity ;  some 
cases  of  imbecility. 

Ill-being,  Sense  of. — Profound  in  simple  melancholia.  In  neu- 
rasthenia and  neurasthenic  insanity. 

Illusions. — An  illusion  is  a  transformation  of  a  peripheral  sensa- 
tion (Griesinger).  "In  scientific  works  treating  of  the  pathology 
of  the  subject,  the  word  ("illusion")  is  confined  to  what  are 
specially  known  as  illusions  of  the  senses,  that  is  to  say  to  false 
or  illusory  perceptions.  And  there  is  very  good  reason  for  this 
limitation  since  such  illusions  of  the  senses  are  the  most  palpable 
and  striking  symptoms  of  mental  disease.  In  addition  to  this  it 
must  be  allowed  that,  to  the  ordinary  reader,  the  term  first  of  all 
calls  up  this  same  idea  of  a  deception  of  the  senses "  (Sully, 
"Illusions,"  pp.  4-5).  "The  slight,  scarcely  noticeable  illusions 
of  normal  life  lead  up  to  the  most  startling  hallucinations  of 
aVtnormal  life.  From  the  two  poles  of  the  higher  centres  of 
attention  and  imagination  on  the  one  side,  and  the  lower  regions 
of  nervous  action  involved  in  sensation  on  the  other  side,  issue 
forces  which  may,  under  certain  circumstances,  develop  into  full 
hallucinatory  percepts.  Thus  closely  is  health  attached  to  morbid 
mental  life"  (Sully,  op.  cif.,  pp.  120-121).  If  a  patient  believes 
a  perfect  stranger  really  present  to  l;)e  some  intimate  friend,  or 
that  an  inarticulate  shout  is  a  word  of  reproach  or  a  name,  he  is 
the  subject  of  an  illusion.  But  if  he  hears  a  voice  where  no  sound 
has  been  emitted,  or  sees  a  person  Avhere  no  one  is  present,  he  is 
the  subject  of  a  hallucination.  If  he  belieA^es  that  taking  food 
will  cause  him  to  lose  his  soul,  or  that  he  has  many  millions  of 
pomids  hidden  somewhere  under  a  stone,  or  that  he  is  God,  or 
that  he  has  committed  the  unpardonable  sin,  he  is  labouring 
under  a  delusion.  A  sane  person  may  suffer  from  illusions  and 
hallucinations ;  but  if  he  begins  to  think  they  are  real  and  acts  in 
accordance  with  that  idea,  he  becomes  insane.  A  person  with  a 
decided  delusion  can  hardly  be  called  sane.  Illusions  are  common 
in  semi-insane,  weakly  eccentric  people,  and  render  them  a 
nuisance  to  themselves  and  all  about  them.  Illusions  are  not  so 
common  in  monomania  and  melancholia  as  hallucinations,  Ijut  are 
more  frequent  than  the  latter  in  mania.  They  occur  more 
frequently  than  either  hallucinations  or  delusions  in  periodical 
insanity.  Illusions  may  affect  one  or  all  of  the  senses : 
(1,)  Visual. — The  most  frequent  form  of  illusion.  Illusions  of 
sight  generally  relate  to  persons  (Spitzka).  Visual  illusions 
should  be  distinguished  from  optical  illusions ;  the  latter  being 


WITH   THE   MENTAL   DISEASES    IN   WHICH   THEY   OCCUR.       29 

phenomena  of  refraction  and  reflection  are  entirely  objective,  and 
may  be  perceived  by  many  jjei-sons  simultaneously ;  the  mirage 
of  the  desert  is  an  example.  Visual  illusions  occur  in  periodical 
insanity ;  early  stages  of  toxic  insanity  ;  early  on  in  acute  mania ; 
persecutory  delusional  insanity  (monomania  of  suspicion);  general 
paralysis.  (2,)  Auditory. — In  toxic  insanity  ;  persecutory  delu- 
sional insanity ;  periodical  insanity ;  mania.  (3,)  G-ustatonj. — Often 
arise  from  furred  tongue.  So-called  hallucinations  of  taste  are 
often  really  illusions.  They  frequently  disappear  with  the  relief 
of  dyspepsia  (Spitzka).  In  hypochondriacal  melancholia  (hypo- 
chondriacal insanity);  persecutory  delusional  insanity.  (4,) 
Olfactory. — So-called  hallucinations  of  smell  are  often  really  illu- 
sions, as  there  is  some  slight  odour  which  is  much  exaggerated 
and  altered  in  the  consciousness  of  the  patient.  Melancholies 
(especially  masturbatory  neurasthenics)  sometimes  fancy  they 
emit  a  horrible  odour  themselves.  (5,)  Tactile,  Chttaneous,  or 
of  General  Sensibilify.- — Touch  often  suffers  from  illusions 
(Bucknill  and  Tuke).  (6,)  Visceral. — So-called  visceral  halluci- 
nations are  often  illusions  arising  from  cancer  of  the 
stomach,  etc.  In  hypochondriacal  melancholia.  (7,)  Sexual 
(Griesinger). — In  erotic  delusional  insanity  (monomania  of 
suspicion). 

Imagination  Weakened. — In  chronic  alcoholic  insanity. 

Immoral,  Grossly  and  Openly.— In  general  paralysis ;  impulsive 
insanity  ;  moral  insanity  ;  simple  mania. 

Impatience. — In  chronic  hysterical  insanity. 

Imperative  Conceptions.— ("Fixed  Ideas,"  "  Zwangsvorstel- 
lungen ") ;  Eefiections  and  suspicions  which  tyrannise  the 
patient's  thoughts  and  sometimes  his  acts  as  markedly  as 
the  most  firmly  rooted  organised  insane  idea.  They  differ  from 
the  delusion  in  that  the  patient  is  able  to  reason  himself  out 
of  them,  and  to  recognise  their  absmxlity  at  times.  They 
arise  suddenly  without  any  obvious  connection  with  previous 
thoughts ;  they  appear  like  spontaneous  explosions  of  some 
uncontrolled  segment  of  the  nervous  system.  They  sometimes 
arise  from  suggestions  cj[uite  inadequate  to  produce  such  impressions 
in  a  healthy  state.  Agoraphobia  (fear  of  open  places),  clau- 
strophobia (fear  of  narrow  quarters),  mysophobia  (fear  of  defile- 
ment), are  examples  of  imperative  conceptions  which  remain  in 
statu  quo  for  years.  Imperative  conceptions  are  more  common  in 
females  than  in  males,  in  youthful  and  imbecile  than  in  aged  and 
strong-minded  persons,  and  under  such  conditions  as  pregnancy, 
menstruation,  and  the  convalescence  from  fevers  ;  it  may,  there- 
fore, be  assumed  that  there  is  a  morbid  impressionability  of  the 
nervous  system  in  these  cases.     The  imperative  conception  often 


•30  INDEX   OF   SYMPTOMS    SOMATIC   AND    PSYt^HICAL, 

leads  to  the  imperative  act  (morbid  impulse)  (Spitzka,  "  Insanity," 
pp.  35-36). 

They  may  he  (1,)  Contimiom. — In  monomania,  imbecility,  folie 
du  doute,  and  partial  emotional  aberration;  (2,)  Pe nodical. — 
In  jDeriodical  insanity;  or  (3,)  Episodical. — In  melancholia, 
hysterical  insanity,  general  paralysis,  monomania,  imbecility 
(Spitzka);  partial  emotional  aberration;  senile  insanity;  some 
■cases  of  chronic  mania. 

Improvidence  and  Absurdity  of  Actions. — In  confirmed  general 
paralysis.     Simple  mania. 

Impulsive  Acts  (Morbid  Impulses). — The  result  of  defective 
inhibition.  These  acts  may  be  performed  (1,)  Consciousli/.—In 
mania;  imbecility;  moral  insanity ;  dementia;  (2,)  Unconscioushj. 
In  epileptic  insanity  ;  in  somnambulism  ;  under  the  influence 
of  hypnotism;  (3,)  Sometimes  Coiisciousli/,  Sometimes  Uncomciousli/. 
In  impulsive  insanity. 

There  are  many  forms  of  morbid  impulse,  to  destroy,  to  kill, 
to  steal,  etc.,  etc.  (a,)  Destroy,  Impulse  to. — Destructive  mania. 
In  mania;  imbecility;  moral  insanity;  dementia;  (/>,)  Drink, 
Impulse  to. — Dipsomania  (a  form  of  imj)ulsive  insanity).  In 
periodical  mania ;  circular  insanity  ;  climacteric  insanity  ;  gesta- 
tional insanity  ;  (c,)  Exhume  and  Eat  Dead  Bodies  (Clouston),  or 
Defile  Dead  Bodies  (Spitzka),  Impulse  to. — Xecrophilism  ;  (d,)  Kill, 
Impulse  to. — Homicidal  mania  (a  form  of  impulsive  insanity).  In 
puerperal  insanity ;  epileptic  insanity ;  traumatic  insanity ; 
alcoholic  insanity,  especially  mania  a  piota  ;  religious  delusional 
insanity  (religious  monomania) ;  occasionally  in  severe  gestational 
insanity  ;  imbecility,  some  cases ;  sometimes  in  mastiu-bational 
insanity;  {e,)  Sexual  Impulse. — Satyriasis  in  the  male,  nympho- 
mania in  the  female  (forms  of  impulsive  insanit}^).  In  periodical 
mania;  acute  epileptic  insanity;  (/,)  Steal,  Impulse  to. — Klepto- 
mania (a  form  of  impulsive  insanity).  In  periodical  mania ; 
gestational  insanity  ;  imbecility  ;  chronic  mania  ;  incipient  general 
paralysis;  {g,)  Suicidal  Impulse,  uithout  Depression. — Suicidal 
mania  (a  form  of  impulsive  insanity).  In  puerperal  mania ; 
acute  epileptic  insanity;  religious  monomania;  {h).  The  Incendiarji 
Impulse. — Pyromania  (a  form  of  imiDulsive  insanity).  In  periodical 
insanit}' ;  acute  epileptic  insanity  ;  religious  monomania  ;  pubes- 
cent insanity ;  some  cases  of  expansive  syphilitic  insanity ; 
{%,)  JVamler  from  Home  and  throw  off  the  Ft,estraints  of  Society, 
Impulse  to. — Planomania  (Clouston);  (/,)  Wild  Beast,  Impxdse  to  act 
like. — ^Lycanthropia. 

Incoherence. — In  pubescent  insanity:  acute  mania  ;  general  par- 
alysis; imbecility;  acute  or  primary  confusional  insanity;  absolute 
in   acute   delirium   (acute   delirious   mania) ;    agitated   terminal 


WITH   THE   MENTAL   DISEASES    IN   WHICH   THEY   OCCUR.       31 

dementia ;  alcoholic  insanity ;  epileptic  insanity ;  puerperal 
insanity  ;  senile  insanity  :  maniacal  saturnine  insanity ;  transitory 
mania ;  syphilitic  depression  with  incoherence ;  may  be  absolute 
in  maniacal  true  rheumatic  insanity  ;  insanity  with  exophthalmic 
goitre ;  sometimes  in  chronic  mania. 

Inconsistencies  in  Speech  and  Acts. — Prodromal  of  general  par- 
alysis. 

Indecision. — In  organic  melancholia ;  chronic  hysterical  insanity  ; 
partial  dementia. 

Indiiference. — In  some  cases  of  simple  melancholia. 

Inertia. — In  primary  mental  detei^ioration  (simple,  primary 
dementia) ;  prodromal  of  anergic  stupor  (acute  dementia) ;  in 
simple  melancholia ;  organic  melancholia  ;  climacteric  insanity  ; 
insanity  of  oxaluria  and  phosphaturia. 

Infantile  Convulsions,  Succeeding. — Eclampsic  idiocy. 

Inhibition,  Loss  of  Power  of. — In  impulsive  insanity ;  in  many 
cases  of  epileptic  insanity,  imbecility,  climacteric  insanity,  melan- 
cholia, puerperal  insanit}^,  gestational  insanity,  pubescent  insanity, 
periodical  insanity. 

Injuring  Husband  and  Children. — In  puerperal  insanity  ;  climac- 
teric insanity. 

Injuring  Self. — Self-injury  apart  from  suicidal  tendency  and  as  a 
result  of  excitement,  terror,  delusions,  or  unconsciousness  occurs 
in  acute  mania  ;  pubescent  insanity  ;  agitated  melancholia  ;  puer- 
peral insanity ;  monomania ;  epileptic  insanity ;  delirium 
tremens. 

Inquietude. — In  depressive  intellectual  petit  mal ;  prodromal  of 
acute  delirium  (acute  delirious  mania) ;  premonitory  of  acute 
mania ;  in  early  delusional  insanity  (monomania) ;  in  neurasthenia 
and  neurasthenic  insanity. 

Insomnia. — In  primary  mental  deterioration  (simple  primary 
dementia),  prodromal  period,  and  fully-developed  disease  ;  climac- 
teric insanity ;  senile  insanity  ;  pubescent  insanity ;  adolescent 
insanity;  puerperal  insanity ;  lactational  insanity  ;  acute  delirium ; 
delirium  tremens ;  general  paralysis  ;  at  night  with  drowsiness 
after  meals  prodromal  of  general  paralysis ;  epileptic  insanity  ; 
prodromal  of  acute  epileptic  insanity;  in  melancholia;  severe  simple 
mania,  acute  mania  (usually  also  a  premonitory  symptom),  chronic 
mania  (often),  transitory  mania ;  phthisical  insanity ;  organic 
dementia,  especially  in  cases  with  neurotic  heredity  ;  complete  in 
expansive  syphilitic  insanity  ;  incipient  true  rheumatic  insanity  ; 
neurasthenia  and  neurasthenic  insanity  ;  insanity  from  opium ; 
chloral  insanity ;  incipient  saturnine  insanity ;  post-febrile  con- 
secutive insanity ;  traumatic  insanity ;  insanity  of  cyanosis  from 
bronchitis,  etc. ;  insanity  of  myxcedema. 


32  INDEX   OF   SYMPTOMS    SOiLlTIC   AND    PSYCHICAL, 

Instability.— Prodromal  of  general  paralysis ;  in  syphilitic 
depression  Avith  incoherence. 

Instructed,  Incapable  of  being. — In  congenital  moral  insanity 
(moral  imbecility). 

Intellectual  Faculties  Absent. — In  some  cases  of  idiocy ;  some 
cases  of  cretinism  ;  advanced  terminal  dementia. 

Interest,  Loss  of,  in  Surroundings. — In  the  tumour  form  of 
insanity  from  coarse  brain  disease ;  monomania  ;  lucid  or  sub- 
lucid  intervals  of  long-standing  periodical  insanity. 

Intestinal  Disturbances. — Often  at  menstrual  periods  in  chronic 
hysterical  insanity. 

Introspection  Shallow  and  Conceited. — In  incipient  masturba- 
tional  insanity. 

Irascibility.— In  epileptic  insanity  ;  imbecility ;  simple  melancho- 
lia ;  early  chronic  hysterical  insanity  ;  choreic  insanity  ;  incipient 
true  rheumatic  insanity  ;  traumatic  insanity  ;  partial  exaltation ; 
sub-lucid  intervals  of  long-standing  periodical  insanit3^ 

Irritability. — In  epileptic  insanity ;  alcoholic  insanity ;  imbecility ; 
}jersecutory  monomania ;  phthisical  insanity ;  early  puerperal 
insanity ;  insanity  from  coarse  brain  disease,  tumoui'  form ; 
chronic  hysterical  insanity ;  excessive  in  early  choreic  insanity  ; 
traumatic  insanity ;  second  stage  of  masturbational  insanity ; 
nem-astjienic  neurosis  and  psychosis  :  lactational  insanity  ;  senile 
melancholia  ;  simple  melancholia  :  hypochondriacal  melancholia  ; 
climacteric  insanity  ;  incipient  rheumatic  insanity  ;  partial  exal- 
tation ;  lucid  interA-als  of  periodical  insanity  ;  insanity  of  oxalm^ia 
and  phosphatiu^ia ;  insanity  from  deprivation  of  senses.  It  is  a 
symptom  of  brain  exhaustion. 

'  Jaws,  Champing  of. — In  the  second  stage  of  confirmed  general 
paralysis. 

Jealousy,    Insane. — In   jealous    monomania  :    chronic    alcoholic 

insanity. 

Judgment,  Defective. — In  imbecility  ;  simple  raaiiia  ;  prodromal 
of  general  paralysis. 

Kill,  Impulse  to. — See  "  Impulsive  Acts." 

Language,  Blasphemous  or  Obscene,  or  Both. — Lial)le  to  occur  in 
many  forms,  but  most  frequenth'  and  markedly  in  puerperal 
insanity,  climacteric  insanity,  epileptic  insanit}',  chronic  mania, 
iml^ecility,  and  general  paralysis. 

Lassitude. — One  of  the  prodromata  of  acute  delirium  and 
general  paralysis  ;  a  prodroma  of  primary  mental  deterioration. 
In  neiu"asthenia. 

Laughter,  Bursts  of. — In  expansive  intellectual  petit  laal ;  acute 
mania  ;  expansive  s3'-philitic  insanity. 

Laziness. — In  epilepsy  ;  simple  melancholia. 


WITH   THE   MENTAL   DISEASES   IN   WHICH   THEY   OCCUR.       33 

Lethargy. — In  lactational  insanity. 

Limited  Speech  or  Action,  or  Both. — In  all  forms  of  melancholia. 

Listlessness. — In  advanced  post-febrile  consecutive  insanity ; 
apathetic  terminal  dementia. 

Localised  Paralysis  or  Paresis. — See  "  Paralysis." 

Lochia  Altered,  Diminished,  or  Suppressed. — Often  in  puerperal 
insanity. 

Locomotion,  PositiYe  Disturbances  of.  —In  general  paralysis  ; 
syphilitic  dementia  ;  acute  delirium ;  organic  dementia  ;  epileptic 
insanity ;  alcoholic  insanity. 

Loquacity. — In  acute  mania ;  maniacal  phase  of  circular  insanity ; 
puerperal  mania ;  delirium  tremens  ;  mania  a  jJotu ;  early  expansive 
general  paralysis ;  senile  mania ;  ej^ileptic  insanity  during 
paroxysmal  excitement ;  acute  delirium  ;  unceasing  in  expansive 
syphilitic  insanity  ;  simple  mania ;  acute  rheumatic  insanity  ; 
maniacal  form  of  sub-acute  or  true  rheumatic  insanity  ;  partial 
exaltation ;  chronic  mania  ;  agitated  terminal  dementia  ;  adoles- 
cent insanity  ;  imbecility. 

Loss  of  Ability  to  Write. — In  organic  dementia  ;  organic  melan- 
cholia •  advanced  general  paralysis  ;  terminal  dementia  ;  tempor- 
arily in  delirium  tremens. 

Low  Company,  Disposition  to  Keep. — In  moral  insanity. 

Malaise. — Profound  in  depressive  intellectual  petit  mal ;  often 
prodromal  of  melancholia  ;  neurasthenic  neurosis  and  psychosis. 

Manner,  Fierce. — In  some  cases  of  acute  mania. 

Manner,  Foolish — In  simple  mania. 

Manner,  Jolly. — In  some  cases  of  acute  mania. 

Manual  Inability,  Leading  to  Awkv/ardness  in  Manipulations,— 
In  confirmed  general  paralysis. 

Marasmus. — In  incipient  chronic  hysterical  insanity. 

Masturbation. — In  masturbational  insanity  ;  pubescent  insanity ; 
adolescent  insanity  ;  epilej)tic  insanity;  nymphomania;  satyriasis; 
acute  mania  ;  chronic  mania;  early  general  paralysis. 

Memory  DefectiYe.— See  "  Amnesia." 

Memory,  Loss  of.— See  "  Amnesia." 

Mendacity. — In  moral  insanity,  acquired  and  congenital ;  simple 
mania  ;  gestational  insanity  ;  maniacal  phase  of  circular  insanity. 

Menstruation  Irregular  or  Profuse,  or  Both. — Towards  climacteric ; 
prodroiiial  of  climacteric  insanity. 

Mental  Enfeeblement. — In  sub-acute,  or  true  rheumatic  insanity 
organic  melancholia;  katatonia.     See  "Mental  Weakness,"  etc. 

Mental  Weakness  (Limited) — In  monomania  (Spitzka). 

Mental  Weakness  Prominently  Developed — See  "  Mental  Enfeeble- 
ment." (a,)  Involving  the  mental  faculties  generally. — In  idiocy ; 
imbecility;  primary  deterioration;  dementia,  whether  terminal, 

3 


34  INDEX   OF  SYMPTOMS   SOMATIC    AND   PSYCHICAL, 

alcoholic,  epileptic,  or  organic  ;  acute  delirium,  (b,)  With  focal 
lacunce. — In  general  paralysis  ;  syphilitic  dementia ;  chronic  alco- 
holic insanity;  chronic  mania;  primary  confiisional  insanity; 
pubescent  insanity  (Spitzka). 

Metastasis. — In  metastatic  insanity  ;  diabetic  insanity ;  rheu- 
matic insanity ;  gouty  insanity. 

Migraine. — Frequently  at  menstrual  periods  in  chronic  hysterical 
insanity. 

Misanthropic. — In  some  cases  of  imbecility. 

MischicYousness  and  Mockery,  Tendency  to. — In  maniacal  phase  of 
circular  insanity. 

Moaning — In  melancholia  ;  senile  melancholia. 

Mobility  of  Character. — In  epilepsy. 

Mobility  of  Ideas. — In  incipient  delusional  insanity  (monomania) ; 
expansive  confirmed  general  paralysis ;  choreic  insanity ;  second 
stage  of  masturbational  insanity. 

Monoparaplegia — See  "  Paralysis." 

Monoplegia — See  "Paralysis." 

Monotony  of  Speech  or  Action  or  Both. — In  all  forms  of  melancholia. 

Monotony  of  Thoughts  and  Movements In  melancholia. 

Mood,  Quickly  Changing — In  alcoholic  insanity  ;  second  stage  of 
masturbational  insanity. 

Moral  Deterioration. — In  acquired  moral  insanity  ;  simple  mania  ; 
early  general  paralysis ;  senile  dementia ;  advanced  chronic  alco- 
holic insanity;  folie  circulaire  (circular  insanity);  periodical 
insanity;  one  of  the  jDrodromata  of  general  paralysis. 

Moral  Perverseness — In  traumatic  insanity. 

Moral  Perversion — In  periodical  insanity.  (See  "Moral  Deterio- 
ration" and  "Moral  Perverseness.") 

Morbid  Propensities — These  are  perversions  of  the  two  main 
instinctive  tendencies  of  the  human  race  :  the  desire  for  food  and 
the  sexual  appetite.  Anthropophagy  and  sexual  perversions  are 
the  most  important  morbid  propensities  from  a  medico-legal  ^^oint 
of  view.  (Spitzka,  "Insanity,"  p.  38.)  In  pubescent  insanity; 
periodical  insanity. 

Morbid  Sensations  ;  Formication,  etc. — In  some  cases  of  hypochon- 
driacal melancholia. 

Morbid     Sensations    of    Lightness,    Heaviness,    etc Prodromal 

of  general  paralysis. 

Moroseness — In  epilepsy;  some  cases  of  chronic  hysterical 
insanity  in  early  stage ;  traumatic  insanity. 

Motiveless  Actions — In  simple  mania;  depressive  syphilitic 
insanity,  ^Wth  incoherence ;  expansive  syphilitic  insanity. 

Motiveless  Laughter. — In  expansive  syphilitic  insanity ;  alter- 
nating mth  weeping  in  choreic  insanity. 


WITH   THE   MENTAL   DISEASES    IN   WHICH   THEY   OCCUR.       35 

Motor  Restlessness. — See  "  Eestlessness,  Motor." 

Movement,  Aversion  to. — In  simple  melancholia. 

Muscular  Contractures. — In  insanity  from  coarse  brain  disease  ; 
third  stage  of  general  paralysis,  but  only  temporary  in  uncom- 
plicated cases  of  general  paralysis. 

Muscular  Relaxation. — In  masturbational  insanity  ;  neurasthenia 
and  neurasthenic  insanity. 

Muscular  Resistance,  Diminished. — In  anergic  stupor  (acute  de- 
mentia, acute  primary  dementia). 

Muscular  Sense,  Abolished,  Altered,  or  Hallucinated. — In  con- 
firmed general  paralysis. 

Muscular  Weakness,  not  amounting  to  Paralysis. — In  prodromal 
period  and  beginning  of  first  stage  of  general  paralysis  ;  delirium 
tremens  ;  acute  delirium  ;  primary  mental  deterioration  ;  neuras- 
thenia and  neurasthenic  insanity ;  climacteric  insanity ;  some  cases 
of  traumatic  insanity;  most  marked  in  extensor  muscles  in 
apathetic  terminal  dementia,  and  causes  "VTrist-drop. 

Mutism. — In  anergic  stupor  ;  stuperous  melancholia  ;  most  cases 
of  true  rheumatic  insanity ;  periodical  melancliolia ;  melancholic 
phase  of  f olie  circulaire ;  severe  form  of  cataleptic  insanity ; 
cataleptic  phase  of  katatonia ;  some  cases  of  uterine  insanity ;  a 
few  cases  of  monomania ;  some  cases  of  partial  exaltation ;  some 
cases  of  advanced  general  paralysis. 

Muttering  Isolated  Words. — In  the  third  stage  of  general  paralysis  ; 
terminal  dementia ;  idiocy. 

Naso-Labial  Fold  or  Folds  Flattened  or  Effaced. — In  general 
paralysis  ;  organic  dementia ;  organic  melancholia. 

Natural  Affection,  Loss  of.  —See  "Affective  Sensibility  Perverted 
or  Paralysed." 

Nervous. — In  lucid  or  sub-lucid  intervals  of  periodical  insanity. 

Neuralgia,  General  (and  Mobile)  or  Local. — Prodromal  of  general 
paralysis ;  saturnine  pseudo-general  paralysis ;  prodromal  of  out- 
burst of  periodical  mania,  in  some  cases. 

Neuroses  Affecting  Eye. — In  podagrous  or  gouty  insanity. 

Never  Speaking. — See  "Mutism"  and  "Speech  Congenitally 
Absent  or  Permanently  Lost." 

Nocturnal  Exacerbations. — In  senile  insanity  ;  alcoholic  insanity. 
Noisiness.— In  acute  mania ;  exalted  phase  of  folic  circulaire  ; 
puerperal  mania ;  acute  delirium ;  mania  a  potu ;  delirium 
tremens  ;  agitated  melancholia  ;  paroxysmal  excitement  of 
epileptic  insanity ;  senile  mania ;  general  paralysis ;  organic  de- 
mentia, generally  in  cases  with  neurotic  heredity ;  severe  choreic 
insanity ;  maniacal  form  of  true  rheumatic  insanity. 

Nosophobia. — The  fear  that  serious  illness  is  impending.  In 
neurasthenia  and  neurasthenic  insanity. 


36  INDEX   OF   SYMPTOMS    SOjVIATIC   AND   PSYCHICAL, 

Nystagmus. — Convulsive  oscillation  or  rolling  of  the  eyeball. 
In  idiocy  and  imbecility.  Occasionally  in  acquired  insanity  and 
then,  according  to  Griesinger,  it  is  generally  symptomatic  of  the 
transition  from  the  acute  to  the  chronic  stage. 

Obscenity. — In  puerperal  mania;  gestational  insanity;  severe 
simple  mania. 

Obstinacy. — In  resistive  melancholia;  persecutory  delusional 
insanity. 

Occupation,  Change  of. — One  of  the  prodomata  of  general  paralysis. 

Oddness  and  Peculiarity  from  Birth.— In  congenital  moral  insanity 
(moral  imbecility). 

Odour  Exhaled. — Alcoholic  in  delirium  tremens ;  breath  mal- 
odorous in  acute  delirium,  masturbational  insanity,  acute 
epileptic  insanity,  chronic  mania,  terminal  dementia,  and  in  all 
cases  where  food  is  refused.  The  skin  often  emits  a  repulsive, 
acrid,  ammoniacal  odour  in  the  third  stage  of  general  paralysis. 
So-called  "mousey"  odour  in  room  during  or  after  attacks  of 
maniacal  excitement.     Bromides  impart  haleine  odour  to  breath. 

CEdema. — In  anergic  stupor  (acute  dementia). 

Olfactory  Hallucinations.— See  "  Hallucinations." 

Optic  Nerve  Changes,  Atrophy,  etc. — Prodromal  of  general  paralysis 
in  some  cases  ;  atrophy  in  general  paralysis  in  many  cases  (Clifibrd 
Allbutt,  AYigiesworth.  etc. ).  According  to  Aug.  Voisin,  tortuosity 
of  the  retinal  arteries  is  more  frequent  in  the  third  stage  of 
general  paralysis  than  optic  nerve  atrophy.  According  to  Clifford 
Allbutt,  the  disc  is  pale  from  ischsemia  cWing  an  attack  of  maniacal 
excitement,  but  is  obsciu'ed  by  the  general  redness  of  the  fundus 
after  the  subsidence  of  the  attack. 

Optic  Neuritis. — In  insanity  from  coarse  brain  disease  when 
caused  by  tumom\ 

Originating  Power,  Want  of. — In  insanity  of  oxaluida  and  phos- 
phatmia  ;  neurasthenia  and  neurasthenic  insanity. 

Othsematoma.— See  "  Ha^matoma  Auris." 

Overwhelmed,  Apparently.— In  melancholic  true  rheumatic  in- 
sanity (the  most  common  form  of  true  rheumatic  insanity). 

Own  Words  and  Acts,  Paying  Extreme  Attention  to. — In  folie  du 
doute. 

Painful  Ideas. — In  incipient  delusional  insanity. 

Painful  Morbid  Sensations :  Heat,  Cold,  Pressure,  etc. — Prodromal 
of  general  paralysis  ;  in  neurasthenia  and  neurasthenic  insanity. 

Pain,  Mental. — In  organic  melancholia ;  simple  melancholia. 

Pain,  Mental,  Outward  Signs  of.— In  melancholia ;  senile  melan- 
cholia ;  persecutory  monomania. 

Pains. — In  general  paralysis  (prodromal  period  and  first  stage) ; 
alcoholic  insanity ;  saturnine  insanity;  syphilitic  insanity. 


WITH  THE   MENTAL   DISEASES   IN   "^THICH   THEY   OCCUK.       37 

Pallor. — In  anaemic  insanity;  lactational  insanity;  face  pale  and 
earthy  with  red  malar  prominences  in  acute  delirium ;  chronic 
hysterical  insanity ;  early  masturbational  insanity. 

Palpitation. — In  masturbational  insanity;  early  lactational  in- 
sanity ;  prodromal  period  of  general  paralysis ;  in  neurasthenia 
and  neurasthenic  insanity. 

Paraplegia. — See  "Paralysis  and  Paresis." 

Paralysis  and  Paresis. — Motor  paralysis  may  be  incomplete  in 
degree  or  partial  in  extent ;  example  of  latter,  ptosis.  Paresis,  a 
term  used  by  some  authors  to  indicate  a  milder  degree  of  paralysis. 
Hemiplegia  =  paralysis  of  the  whole  of  one  side  ;  ononoparaplegia  or 
hemiparaplegia  or  crural  monoplegia  =  paralysis  of  one  leg ;  facial 
monoplegia  =  paralysis  of  one  side  of  face ;  brachial  m/)noplegia  = 
paralysis  of  one  arm  ;  brachio-crural  monoplegia  =  paralysis  of  arm 
and  leg  on  same  side ;  paraplegia  =  paralysis  of  both  lower 
extremities  ;  lingual  monopjlegia  =  paralysis  of  one  side  of  tongue  ; 
diplegia  =  paralysis  of  both  arms,  etc. 

All  forms,  but  most  commonly  hemiplegia,  in  insanity  from 
coarse  brain  disease  ;  all  forms  in  general  paralysis ;  transient 
hemiplegia  in  senile  melancholia  ;  paraplegia  and  hemiplegia  in 
senile  dementia  ;  incomplete  paralysis  of  arms  and  legs  in  severe 
delirium  tremens  ;  incomplete  partial  paralyses  commencing  at 
distal  extremities  of  limbs  in  chronic  alcoholic  insanity ;  para- 
plegia in  alcoholic  dementia  of  females  ;  commencing  at  distal 
ends  of  limbs  in  alcoholic  pseudo-general  paralysis ;  affecting 
flexor  muscles  of  arms  and  respecting  supinator  longus  in  saturn- 
ine pseudo-general  paralysis  ;  pronounced  and  partial  {e.  g.  ptosis) 
in  syphilitic  pseudo-general  paralysis ;  in  idiocy  (mostly  in 
paralytic  idiocy)  may  take  form  of  either  hemiplegia  or  para- 
plegia ;  in  imbecility  ;  partial  and  especially  affecting  the 
muscles  of  the  eyeball  in  traumatic  insanity ;  in  hysterical 
insanity  ;  pneumonic  consecutive  insanity  ;  in  the  third  stage 
of  general  paralysis  the  paralysis  is  real  and  most  frequently 
unilateral. 

Parsimony. — In  moral  insanity  (some  cases). 

Passive  Suffering. — In  simple  melancholia. 

Pathos. — In  katatonia. 

PeeYishness. — In  hypochondriachal  melancholia. 

Penuriousness — In  senile  dementia. 

Periodicity. — In  periodical  insanity ;  adolescent  insanity :  circular 
insanity. 

Persecution,  Ideas  of. — Persecutory  monomania ;  true  rheu- 
matic insanity ;  traumatic  insanity ;  opium  or  morphia  insanity  ; 
post-febrile  consecutive  insanity  ;  katatonia  ;  saturnine  pseudo- 
general    paralysis ;     syphilitic     clepression     with     incoherence ; 


3  8  INDEX   OF   SYilPTOMS   SOIHATIC   AND   PSYCHICAL, 

some    cases    of    depressh^e    general    paralysis ;    some    cases    of 
neurasthenic  insanity  ;  prodroma  of  acute  delirium. 

Perspiration,  Profuse. — In  severe  delirium  tremens ;  acute  rheu- 
matic insanity. 

Photopsia. — In  traumatic  insanity. 

Picking  Fingers. — In  agitated  melancholia. 

Place,  Incorrect  Ideas  of. — In  terminal  (secondary),  alcoholic, 
epileptic,  and  syphilitic  dementia  ;  general  paratysis  ;  some  cases 
of  imbecility. 

Poisoning,  Ideas  of. — In  persecutory  or  susj^icious  monomania ; 
phthisical  insanity ;  alcoholic  insanity ;  opium  insanity  ;  saturnine 
pseudo-general  paralysis  ;  acute  delirium  ;  katatonia. 

Premature  Grayness. — In  primary  mental  deterioration  (simple 
primary  dementia) ;  chronic  mania  ;  terminal  dementia. 

Presentiments  of  Evil. — Prodromal  of  general  paralysis,  acute 
delirium,  and  acute  mania  ;  neurasthenia. 

Pressure  or  Fulness  in  Head,  Sensation  of. — In  primary  mental 
deterioration  (simple  primary  dementia) ;  neurasthenia. 

Propensities,  Morbid. — See  "  Morbid  Propensities." 

Prostration. — Extreme  in  dejDressive  intellectual  petit  mal ;  in 
most  cases  of  true  rheumatic  insanity ;  during  remissions  of 
insanity  of  Bright's  disease. 

Ptosis. — In  syphilitic  insanity  ;  general  j)aralysis ;  satm^nine 
insanity. 

Pulling  Out  Hair. — In  agitated  melancholia. 

Punctiliousness. — At  commencement  of  folie  du  doute  (dubious 
or  doubting  insanity). 

Pupils,  Dilated. — In  hysterical  insanity ;  anergic  stupor  (acute 
dementia) ;  stuporous  melancholia  (melancholia  attonita) ;  general 
paralysis  in  the  later  stages ;  some  cases  of  neurasthenic  insanity. 

Pupils,  Dilated  and  Immobile. — In  stuporous  melancholia. 

Pupils  Extremely  Contracted. — Prodromal  of  general  paralysis. 

Pupils,  Fixed, — Prodromal  of  general  paralysis. 

Pupils,  Irregular.— In  general  j^aralysis  ;  syphilitic  insanity  and 
syphilitic  pseudo-general  paralysis. 

Pupils,  Mobile. — In  epileptic  insanity. 

Pupils  Unequal. — In  general  paralysis ;  simple  primary  deterio- 
ration; alcoholic  pseudo-general  paralysis;  satiu^nine  pseudo-general 
paralysis  ;  sometimes  unequally  contracted  in  severe  delirium  tre- 
mens ;  occasionally  unequal  in  mania  (acute  and  chronic) ;  hysterical 
insanity ;  liable  to  occur  in  all  forms  of  insanity  as  a  resvilt  of 
aneurism,  bromism,  cervical  wounds,  tumours,  dental  caries,  etc. 

Pulse. — Small  and  frequent  in  anergic  stupor ;  compressible 
with  dicrotism  in  general  paralj^sis;  according  to  Broadbent  ("  The 
Pulse,"  p.  275)  general  paralysis  in  its  early  stages  usually  has  the 


WITH   THE   MENTAL   DISEASES   IN   WHICH   THEY   OCCUE.       39 

arteries  contracted  and  a  pulse  of  tension,  later  the  pulse  becomes 
weak  and  toneless.  High  ascent,  flat  top,  interrupted  wavy 
descent,  characteristics  of  sphygmogram  of  general  paralysis 
(Voisin).  Frequent  (may  reach  150),  small,  and  irregular  in  acute 
delirium.  Frequent  (sometimes  120  or  more),  weak,  and  thready 
in  puerperal  mania.  Weak  in  phthisical  insanity.  Small  and 
often  accelerated  in  severe  delirium  tremens ;  accelerated  in  com- 
mencing saturnine  insanity  and  in  the  fully  developed  psychosis. 
Slow  and  small  in  simple  melancholia ;  according  to  Broadbent 
high  arterial  tension  is  usual  in  melancholia,  and  where  extremely 
low  tension  is  j)resent  the  prognosis  is  bad.  In  mania  the  pulse 
is  "  singularly  little  affected  "  (Broadbent).  Small  and  frequent 
in  acute  rheumatic  insanity  ;  frequent  in  sub-acute  or  true  rheu- 
matic insanity.  Insomnia  is  sometimes  associated  with  high 
arterial  tension,  sometimes  with  low.  In  the  former  case  a 
mercurial  aperient  lowers  the  tension  and  procures  sleep,  and  in 
the  latter,  change  of  air  and  vascular  tonics — iron,  acids,  strych- 
nine, and  digitalis  are  appropriate  measures  (Broadbent). 

Quarrelsomeness. — In  traumatic  insanity. 

Quietude. — In  insanity  from  deprivation  of  senses. 

Reaction  Time. — The  reaction  to  acoustic  and  optic  stimuli  is 
abnormally  slow  in  acute  and  sub-acute  mania,  melancholia,  alco- 
holic insanity,  and  epileptic  insanity  (LeAvis). 

Reaction  to  Alcohol  or  Drugs  Increased. — In  traumatic  insanity  ; 
prodromal  of  general  paralysis. 

Reflexes  Exaggerated. — In  insanity  from  coarse  brain  disease  ; 
acute  delirium ;  many  cases  of  general  paralysis  (rather  more 
than  a  third  according  to  Lewis)  ;  some  cases  of  neurasthenic 
insanity. 

Refusal  of  Food. — In  melancholia  in  all  its  forms  ;  puerperal 
insanity  ;  chronic  alcoholic  insanity  ;  delirium  tremens ;  mania  a 
potu ;  persecutory  delusional  insanity ;  phthisical  insanity ; 
alcoholic  pseudo-general  paralysis ;  insanity  from  opium  or 
morphia  ;  post-febrile  consecutive  insanity  ;  prodromal  of  acute 
epileptic  insanity ;  some  cases  of  chronic  hysterical  insanity  ; 
most  cases  of  sub-acute  or  true  rheumatic  insanity ;  diabetic 
insanity ;  katatonia. 

Relatives  and  Friends,  Unreasonable  Antipathy  to. — To  husband 
in  severe  gestational  insanity.  (See  "  Affective  Sensibility,  Per- 
verted or  Paralysed.") 

Religious  Tinge. — In  some  cases  of  hysterical  insanity. 

Remorse. — In  climacteric  insanity. 

Repetition  (Constant)  of  Same  Words  to  Self. — In  folie  du  doute. 

Repetition  (Frequent)  of  One  Word  or  Phrase. — In  chronic  mania  ; 
idiocy ;  terminal  dementia. 


40  INDEX   OF   SYMPTOMS   SO]\IATIC   AND   PSYCHICAL, 

Reproductive  Faculties  Absent. — In  some  cases  of  idiocy  ;  some 
cases  of  cretinism. 

Repugnance  to  Husband. — In  puerperal  insanity;  often  in 
climacteric  insanity  ;  scA^ere  gestational  insanity.  (See  "  Affective 
Sensibility,  Perverted  or  Paralysed. ') 

Resistance  to  Movement,  Feeding,  etc. — In  stuporous  melancliolia 
(melancholia  attonita,  melancolie  avec  stupeur). 

Respirations,  Affected. — Slow  and  irregular  in  simple  melan- 
cholia ;  accelerated  in  puerperal  mania,  in  some  cases  56  or  60  ; 
early  lactational  insanity  ;  acute  rheumatic  insanity. 

Restlessness,  Mental. — In  agitated  terminal  dementia ;  simple 
mania  ;  chronic  mania  ;  hypochondriacal  melancholia  ;  climac- 
teric insanity  ;  prodromal  of  general  paralysis. 

Restlessness,  Motor. — In  acute  delirium  (acute  delirious  mania) ; 
acute  mania ;  most  cases  of  sub-acute,  chronic,  and  delusional  mania ; 
severe  simple  mania;  periodical  insanity  (maniacal  form);  circular 
insanity  (maniacal  phase) ;  extreme  in  agitated  melancholia ; 
agitated  terminal  dementia  ;  senile  insanity,  especially  at  night ; 
pubescent  insanity ;  adolescent  insanity  ;  delirium  tremens ; 
some  cases  of  climacteric  insanity ;  incipient  true  rheumatic 
insanity  and  maniacal  form  of  developed  true  rheumatic  insanity ; 
third  or  maniacal  stage  of  masturbational  insanity  ;  extreme  in 
insanity  of  Bright's  disease ;  insanity  of  myxcedema  (some 
cases);  organic  dementia,  worst  cases,  those  with  neurotic 
heredity  (Clouston) ;  one  of  the  prodromata  of  general 
paralysis. 

Retention  of  Urine. — From  indifference  or  from  diminished 
sensibility,  atony,  or  paralysis  of  bladder.  In  melancholia ; 
acute  delirium  ;  insanity  from  coarse  brain  disease. 

Retina,  Changes  in. — Anaemia  of  retina  frecjuent  in  melancholia 
(Allbutt).  In  mania  if  there  is  decided  excitement  retinal  con- 
gestion is  often  met  -ttdth  (Monti).  Eetinal  arteries  very  frequently 
tortuous  in  third  stage  of  general  paralysis  (Voisin).  Albumin- 
uric retinitis  in  insanity  of  Bright's  disease.  Choroido-retinitis  in 
some  cases  of  syphilitic  insanity. 

Rhyming  Speech. — In  katatonia  ;  pubescent  insanity ;  epileptic 
mental  states  ;  sometimes  in  any  episodical  excitement  (Spitzka). 

Rhythmical  Movements. — In  acute  mania  ;  apathetic  terminal 
dementia. 

Rigidity,  Cataleptic. — In  cataleptic  insanity ;  katatonia  ;  melan- 
cholic forms  and  stages  of  pubescent  insanity. 

Rigidity  of  Muscles,  of  Trunk,  or  Extremities. — In  confirmed 
general  paralysis. 

Sallowness. — In  phthisical  insanity ;  stuporous  melancholia ; 
saturnine  insanity. 


WITH   THE   aiENTAL   DISEASES    IN   WHICH   THEY   OCCUR.       41 

Satisfaction,  Ideas  of. — In  expansive  general  paralysis ;  expansive 
intellectual  petit-mal ;  partial  exaltation. 

Satyriasis. — A  form  of  impulsive  insanity  and  a  symptom. 
Often  a  sym]3tom  of  senile  insanity,  the  patients  committing 
criminal  assaults  on  youjig  girls  and  even  infants. 

Screaming. — Violent  in  some  cases  of  delirium  of  young  children. 

Secretions,  Diminished. — In  simple  melancholia. 

Self-Abasement. — In  some  cases  of  simple  melancholia. 

Self- Absorption. — In  some  cases-  of  simple  melancholia  ;  most 
cases  of  true  rheumatic  insanity. 

Self-Abuse  (Onanism). — In  masturhational  insanity  ;  satyriasis  ; 
nymphomania  ;  pubescent  insanity ;  adolescent  insanity  ;  chronic 
mania ;  erotomania ;  idiocy  ;  expansive  general  paralysis ; 
epileptic  insanity. 

Self-Accusations  of  Hypocrisy,  Impiety,  etc. — In  religious  melan- 
cholia. 

Self-Confidence,  Loss  of. — In  folie  du  doute. 

Self-Control,  Loss  of. — In  hypochondriacal  melancholia  ;  climac- 
teric insanity  ;  one  of  the  prodromata  of  general  paralysis. 

Self-Esteem,  Sometimes  Exaggerated,  Sometimes  Diminished. — 
In  katatonia. 

Self-Feeling,  Morbid. — In  incipient  masturhational  insanity. 

Self-Injury — See  "Injuring  Self." 

Self-Interrogation. — In  folie  du  doute. 

Self-Mutilation. — In  religious  monomania. 

Self-Reproaches  of  Masturbation,  etc. — In  the  initial  depression 
of  katatonia. 

Senses,  Absence  of  Two  or  More.— In  idiocy  by  deprivation ; 
insanity  by  deprivation. 

Senses  (Special)  Enfeebled.— In  simple  melancholia. 

Senses  (Special)  Supernaturally  Acute.— In  early  stages  of  acute 
mania. 

Sensibility,  Extreme.— In  hypochondriacal  melancholia. 

Sensibility  (General)  Enfeebled  or  Impaired. — In  simple  melan- 
cholia;  anergic  stupor  (acute  dementia);  general  paralysis, 
especially  in  second  and  third  stages. 

Sentences  Uncompleted  (in  Talking). — In  acute  or  primary  con-- 
fusional  insanity.     Early  general  paralysis. 

Sentiments,  Alteration  of. — In  all  forms  of  accjuired  insanity. 

Seriousness  Increased. — In  early  chronic  hysterical  insanity. 

Sexual  Appetite  Diminished.— In  simple  melancholia  ;  confirmed 
general  paralysis ;  in  neurasthenia  except  episodically  (KrafFt- 
Ebing). 

Sexual  Appetite  Lost. — In  the  second  stage  of  confirmed  general 
paralysis  it  is  permanently  lost. 


42  INDEX   OF   SYIMPTOMS    SOIVIATIC   AND   PSYCHICAL, 

Sexual  Excitement, — In  satyriasis  ;  nymphomania  ;  erotomania ; 
religious  monomania ;  f  olie  circuiaire  (maniacal  phase) ;  periodical 
mania  ;  simple  mania ;  prodroma  of  general  paralysis. 

Sexual  Peryersion. — In  impulsive  insanity  ;  periodical  insanity  ; 
moral  insanity ;  simple  mania  ;  early  general  paralysis  ;  pubescent 
insanity  to  the  extent  of  dislike  and  avoidance  of  opposite  sex ; 
folie  circuiaire  (some  cases) ;  masturbational  insanity,  avoidance 
of  opposite  sex. 

Shutting  Eyes. — In  acute  mania. 

Sight,  Impaired. — In  mastui'bational  insanity;  insanity  from 
myxo3dema. 

Similarity  of  Repeated  Attacks  in  same  Patient. — In  acute  epileptic 
insanity  ;  periodical  insanity. 

Sin,  Preoccupation  with  Ideas  About. — In  religious  delusional 
insanity  (theomania,  religious  mania) ;  religious  melancholia ; 
depressive  general  paralysis  (some  cases). 

Sitophobia. — Fear  to  take  food,  resulting  in  refusal  to  take  it. 
In  simple  melancholia. 

Skin,  Changes  in. — Dull  in  tint,  and  either  dry  or  greasy  in 
third  stage  of  general  paralysis  ;  cold  and  clammy  in  masturba- 
tional insanity ;  hard  and  dry  in  insanity  from  myxcedema ;  muddy 
and  more  than  normally  pigmented  in  climacteric  insanity, 
increasing  as  the  disease  progresses. 

Skin  Irritation. — In  climacteric  insanity,  causing  picking  and 
scratching.  One  of  the  prodromata  of  general  paralysis.  In 
insanity  from  coarse  brain  disease  arising  from  softening  of  the 
inferior  siu-face  of  the  temporo-sphenoidal  lobe. 

Sleeping  Badly  and  Sleeplessness. — See  "  Insomnia."  Sleep 
absent,  insufficient,  or  unrefreshing  in  neurasthenia  and  neuras- 
thenic insanity  (Krafft-Ebing). 

Slovenly  and  Untidy. — In  melancholia  ;  acute  and  chronic  mania ; 
general  paralysis. 

Slow  Pulse. — In  melancholia.     (See  "Pulse.") 

Slowness  of  Ideation. — In  simple  depressive  syphilitic  insanity. 

Smell,  Hallucinations  of. —  Disagreeable  in  masturbational 
insanity,  and  with  false  taste  perceptions  almost  characteristic 
(Spitzka).     (See  "Hallucinations.") 

Solitary. — In  the  second  stage  and  the  demented  or  foiirth  and 
last  stage  of  masturbational  insanity.  Desire  for  solitude  in 
simple  melancholia. 

Somatic  Stigmata. — Such  as  cranial  malformations,  unilateral 
atrophy,  dental  irregadarities,  vaulted  palate,  cleft  j)alate,  club 
foot,  etc.,  etc.  In  idiocy,  cretinism,  imbecility,  monomania, 
epileptic  insanity ;  periodical  insanity ;  hysterical  insanity ; 
exceptionally  and  then  non-essential  in  all  other  forms  (Spitzka). 


WITH   THE   MENTAL   DISEASES   IN   WHICH   THEY   OCCUR.       43 

Sombreness. — In  early  chronic  hysterical  insanity. 

Sores  on  Extremities,  Tendency  to  the  Formation  of. — In  diabetic 
insanity. 

Speech,  Abnormalities  of. — These  may  be  (a,)  Acquired. — In 
second  stage  of  general  paralysis  slow,  drawling,  and  hesitant 
from  the  cerebral  lesions ;  stammering,  stuttering,  and  tremulous 
from  the  bulbar  ;  it  becomes  unintelligible,  and  in  some  cases  ends 
in  mutism  (Voisin).  The  articulation  is  thick  in  organic  dementia, 
and  the  defect  is  not  greatest  at  the  end  of  a  sentence  as  in 
general  paralysis ;  timid,  hesitant,  and  interrupted  in  simple 
melancholia ;  articulation  affected  in  primary  mental  deteriora- 
tion ;  articulation  often  embarrassed  in  acute  delirium  ;  affected 
in  alcoholic  insanity ;  embarrassed  in  alcoholic  pseudo-general 
paralysis  ;  stammering  in  saturnine  pseudo-general  paralysis,  and 
at  first  often  unintelligible ;  jerky  in  true  rheumatic  insanity  ; 
slow  and  muffled  in  insanity  of  myxoedema  ;  (h,)  Congenital. — In 
idiocy,  imbecility,  monomania. 

Speech  Congenitally  Absent  or  Permanently  Lost. — In  some  cases  of 
idiocy;  some  cases  of  cretinism;  some  cases  of  advanced  terminal 
dementia;  some  cases  of  general  paralysis  in  third  stage. 
(See    "Mutism.") 

Speech,  Senile. — In  senile  insanitj^.  For  description  of  "  senile 
speech,"  see  symjDtoms  of  senile  melancholia  ("Senile  Insanity," 
Chapter  III). 

Spermatorrhoea. — Sometimes  in  masturbational  insanity ;  in 
neurasthenia  and  neurasthenic  insanity. 

Spontaneity  Impaired. — In  climacteric  insanity. 

Squander,  Disposition  to. — In  general  paralysis  ;  simple  mania  ; 
moral  insanity  ;  incipient  acute  mania  ;  imbecility. 

State,  Restless  and  Unsettled,— In  incipient  masturbational 
insanity. 

Statements  Inconsistent  and  Contradictory. — In  primary  mental 
deterioration ;  terminal  dementia ;  organic  dementia  ;  general 
paralysis  ;  mania. 

Stripping  Naked  in  Public. — In  erotomania  ;  organic  dementia  ; 
general  paralysis  ;  nymphomania. 

"  Stunnings." — In  early  general  paralysis  ;  satiu:nine  pseudo- 
general  paralysis. 

Stupidity. — In  post-connubial  insanity. 

Stupor. — In  acute  primary  dementia  (acute  dementia,  anergic 
stupor) ;  with  retention  of  memory  in  melancholia  attonita 
(melancolie  avec  stupeur,  stuporous  melancholia) ;  moderately 
severe  cataleptic  insanity  ;  most  cases  of  true  rheumatic  insanity ; 
uterine  insanity  in  young  women  of  nervous  heredity  ;  sometimes 
in  aneemic  insanity  ;  sometimes  in  epileptic  insanity  ;  sometimes 


44  INDEX   OF   SYMPTOMS   SOMATIC   AND   PSYCHICAL, 

in  general  paralysis ;  transitory  after  acute  mania  (secondary 
stupor,  Clouston). 

Subsultus  Tendinum. — In  acute  delirium  towards  end  ;  severe 
pyretic  delirium  tremens. 

Suicidal  Tendency. — In  suicidal  form  (suicidal  mania)  of  impul- 
sive insanity ;  melancholia,  especially  suicidal  melancholia ; 
alcoholic  insanity ;  puerperal  insanity ;  lactational  insanity ; 
severe  gestational  insanity ;  climacteric  insanity,  but  in  this 
disease  not  usually  intense ;  melancholic  form  of  periodical 
insanity  ;  monomania,  especially  the  religious  form  (theomania), 
sometimes  in  the  persecutory  form ;  sometimes  in  chronic 
hysterical  insanity ;  post-connubial  insanity ;  frequently  in 
pellagrous  insanity ;  some  cases  of  acute  rheumatic  insanity  ; 
sometimes  in  insanity  of  cyanosis  from  bronchitis,  etc. ;  severe 
chloral  insanity;  rarely  in  depressive  syphilitic  insanity ;  epileptic 
insanity. 

Suppression  of  Catamenia. — See  "  Amenorrhoea." 

Surrounding  Persons,  Delusions  as  to. — In  insanity  of  Bright's 
disease. 

Suspiciousness. — In  persecutory  or  suspicious  monomania ; 
lactational  insanity  ;  gestational  insanity ;  phthisical  insanity, 
suspicious  of  being  poisoned  ;  senile  insanity,  suspicious  of  being 
defrauded  or  robbed ;  primary  mental  deterioration ;  semi- 
insanity  with  illusions ;  delirium  tremens ;  chronic  alcoholic 
insanity ;  hypochondriacal  melancholia  ;  true  rheumatic  insanity ; 
traumatic  insanity ;  chronic  morphismus ;  some  cases  of  imbecility ; 
insanity  from  myxcedema  ;  incipient  acute  mania ;  premonitory  of 
melancholia ;  in  nearly  all  forms  in  which  there  are  auditory 
hallucinations. 

Symptoms  Influenced  by  Physiological  Periods. — In  periodical 
insanity. 

Taciturn. — In  simple  melancholia  ;  some  cases  of  persecutory 
monomania. 

Tactile  Hallucinations. — See  "  Hallucinations." 

Talkativeness. — See    "  Loquacity." 

Talking  Incessantly  even  when  Alone. — In  acute  mania. 

Talking  Irrelevantly. — In  acute  or  primary  confusional  insanity. 

Talking  to  Self. — In  mania  ;  monomania  ;  alcoholic  insanity  ; 
imbecility ;  general  paralysis. 

Taste,  Hallucinations  of.— See  "Hallucinations." 

Temperature. — (a,)  Subnornud. — In  anergic  stupor  (acute  primary 
dementia ;  primary  mental  deterioration  (simple  primary  de- 
mentia);  melancholia;  generally  in  third  stage  of  general 
paralysis  ;  in  phthisical  insanity  until  the  lungs  become  affected 
(Clouston) ;  in  insanity  from  myxcedema ;  in  apathetic  terminal 


WITH   THE   MENTAL   DISEASES   IN   WHICH   THEY   OCCUR.       45 

dementia,  {b,)  Supran07inal. — Oscillates  between  102°  and  104°  in 
acute  delirium  (acute  delirious  mania) ;  in  mild  pyretic  delirium 
tremens  from  100°-2  to  101°-4,  in  severe  from  i02°  to  105°-8 
(Magnan);  puerpei'al  mania  in  many  cases,  exceeding  100°  in 
some  and  103°  in  a  few  (Clouston) ;  evening  rise  in  phthisical 
insanity  after  lungs  have  become  affected ;  periodically  in  first 
stage  of  general  paralj^sis ;  in  complicating  delirium  tremens  it 
follows  the  course  of  the  complicating  disease ;  post-febrile  con- 
secutive insanity  (some  cases) ;  in  some  cases  of  acute  mania 
before  the  maniacal  outbui'st  it  may  rise  to  100°;  in  a  few  cases 
of  lactational  insanity,  but  it  rarely  rises  over  100°;  rheumatic 
insanity  is  often  announced  by  a  matutinal  rise  ;  in  acute  rheumatic 
insanity  (acute  cerebral  rheumatism)  it  may  reach  109°,  111°,  or 
even  112°  in  the  rectum;  in  true  rheumatic  insanity  it  is  normal 
or  nearly  so. 

Temperature,  Regional,  of  Head. — In  the  quiescent  mental  state 
the  anterior  region  of  the  head  has  the  highest,  and  the  middle 
region  the  lowest  average  temperature  ;  high  temperatures  occur 
most  frequently  in  the  right  anterior  and  left  posterior  regions. 

The  greatest  elevations  of  temperature  found  at  the  surface,  of 
the  head  during  intellectual  v/ork  of  all  Jcinds  are  usually  met  with 
in  the  space  lying  over  the  tract  of  the  brain-surface  formed 
by  the  posterior  portions  of  the  first  and  second  frontal,  the 
ascending  frontal,  and  the  ascending  parietal  (anterior  part) 
convolutions. 

During  emotional  activity  the  rise  of  tempera tiu-e  is,  in  the 
greater  number  of  cases,  in  all  three  regions,  higher  on  the  left 
side  than  on  the  right ;  the  highest  rises  being  over  the  same 
tract  as  in  intellectual  work  (Lombard). 

In  headache  due  to  overwork  the  temperature  of  the  scalp  over 
the  region  affected  is  higher  than  that  of  the  surrounding  parts 
and  this  can  be  easily  ascertained  by  means  of  an  ordinary 
mercurial  surface  thermometer. 

Temper,  Change  of. — One  of  the  prodomata  of  general  paralysis. 

Temper,  Unequal. — Simple  depressive  syphilitic  insanity. 

Terror. — In  acute  delirium  (acute  delirious  mania). 

Threatening  to  Commit  Suicide. — In  general  paralysis ;  mono- 
mania ;  agitated  melancholia ;  alcoholic  insanity ;  sometimes, 
though  not  by  any  means  always,  in  suicidal  mania  and  suicidal 
melancholia. 

Threatening  Violence  to  Others — In  general  paralysis  ;  mania ; 
periodical  mania  ;  maniacal  phase  of  circular  insanity  ;  persecutory 
monomania  ;  imbecility ;  epileptic  insanity. 

Thyroid  Gland  Affected.— Enlarged  in  many  cases  of  cretinism 
and  in  most  of  insanity  of  exophthalmic  goitre.      Diminished  in 


46  INDEX   OF   SYMPTOMS    SOMATIC   AND    PSYCHICAL, 

size  in  insanity  of  myxoedema.      Affected  in  sexual  neurasthenia 
(Krafft-Ebing). 

Time,  Ideas  of  Incorrect. — In  terminal  dementia ;  alcoholic, 
epileptic,  and  syphilitic  dementia ;  some  cases  of  imbecility. 

Timidity. — At  commencement  of  folie  du  doute. 

Tinnitus  Aurium. — In  traumatic  insanity. 

Tongue. — Furred  in  acute  mania  and  in  melancholia  ;  black  and 
dry  in  acute  delirium ;  displaying  fibrillary  tremor  in  general 
paralysis  and  in  alcoholic,  saturnine,  and  syphilitic  pseudo-general 
paralysis ;  tremulous  and  often  protruded  to  one  side  in  insanity 
from  coarse  brain  disease ;  tremulous  in  chronic  alcoholic  insanity 
and  delirium  tremens  ;  incapable  of  being  protruded  in  advanced 
general  paralysis ;  sometimes  fissured  in  syphilitic  insanity,  and 
bitten  at  the  sides  in  epileptic  insanity. 

Torpidity. — In  mild  cases  of  organic  dementia. 

Torpor,  Mental. — Often  towards  end  of  cyanosis  from  bron- 
chitis, etc. 

Tremor. — May  be  {a,)  General. — In  severe  delirium,  tremens, 
especially  severe  pyretic  delirium  tremens ;  acute  rheumatic 
insanity;  general  and  massive  in  alcoholic  pseudo-general  paralysis; 
general  paralysis.  (&,)  Localised. — Hands  alone,  arms  alone,  arms 
and  legs,  legs  and  face  in  mild  apyretic  and  complicating  delirium 
tremens ;  ataxic  of  upper  and  lower  limbs  in  confirmed  general 
paralysis.  Facial  in  acute  delirium,  acute  mania,  chronic  alcoholic 
insanity,  saturnine  pseudo-general  paralysis,  sometimes  in  syphi- 
litic pseudo-general  paralysis ;  transitory  mania,  episodical  delirium 
of  monomania.  Of  head  and  neck  in  organic  dementia  (where 
there  is  multiple  sclerosis),  insanity  from  paralysis  agitans, 
episodical  excitement  in  mania  and  monomania.  Of  hands  in 
chronic  alcoholic  insanity,  opium  or  morphia  insanity,  acute 
delirium,  general  paralysis,  insanity  of  paralysis  agitans,  saturnine 
insanity,  senile  insanity,  epileptic  insanity,  insanity  vsdth  ex- 
ophthalmic goitre,  syphilitic  pseudo-general  paralysis.  Of  lips 
in  general  paralysis,  saturnine  pseudo-general  paralysis,  sometimes 
in  syphilitic  pseudo-general  paralysis,  acute  delirium,  acute  mania. 
Of  tongue  in  general  paralysis  (from  very  early  stage),  saturnine 
and  syphilitic  pseudo-general  paralysis,  though  often  absent  in 
latter  ;  organic  dementia. 

Trophic  Disturbances  (Special). — In  acute  delirium,  general 
paralysis,  syphilitic  dementia,  organic  dementia,  epileptic  de- 
mentia, melancholia,  terminal  dementia  (Spitzka),  anergic  stupor. 

Unconsciousness,  Apparent.— See  "Apparent  Unconsciousness." 

Unsociability. — In  melancholia;  phthisical  insanity;  climacteric 
insanity;  mastui-bational  insanity,  especially  as  regards  the  oppo- 
site sex. 


WITH   THE   MENTAL   DISEASES   IN   WHICH   THEY   OCCUR.       47 

Unworthiness,  Ideas  of. — In  melancholia  ;  lactational  insanity. 

Upper  Lip,  Swelling  of. — Frequently  in  chronic  hysterical  insanity 
at  menstrual  periods. 

Urine. — Increased  in  general  paralysis ;  urates  increased  and 
chlorides  and  phosphates  diminished  in  general  paralysis  ;  urine 
scanty  in  severe  delirium  tremens ;  rich  in  phosphates  in  anergic 
stupor ;  often  foetid  in  third  stage  of  general  paralysis  ;  loaded  with 
lithates  in  gouty  insanity ;  in  diabetic  insanity  the  sugar  some- 
times alternates  with  the  attacks  of  insanity;  albumen  and  sugar 
should  be  looked  for  in  traumatic  insanity  (Clouston). 

Vacant  Expression.— See  "Facial  Expression,  Vacant." 

Yaciilation. — In  second  stage  of  masturbational  insanity. 

Yague  Fears. — Worse  at  night  in  insanity  of  cyanosis  from 
bronchitis,  etc. 

Yanity. — In  partial  exaltation. 

Yascular  Changes. — In  organic  dementia  and  organic  melancholia, 
atheroma,  etc. ;  fatty  and  fibrous  changes  in  terminal  dementia ; 
dilatations,  atheroma,  etc.,  in  alcoholic  insanity;  dilatations, 
tortuosities,  atheroma,  etc.,  in  general  paralysis ;  temporary  local 
spasm  in  neurasthenia. 

Yaso-Motor  Paresis. — In  anergic  stupor  (acute  dementia). 

Yerbigeration.- -Word-making.  Talking  in  sounds  belonging  to 
no  known  language.     Spitzka  gives  as  an  example,  "Risti  pili 

chinko  ti  ki  ti chichotitonifor  tikohof  or  chink."     In  katatonia, 

epileptic  insanity,  hysterical  insanity,  chronic  confusional  insanity 
(chronic  mania),  pubescent  insanity  (Spitzka). 

Yertigo — See  "  Giddiness." 

Yiolence. — In  epileptic  insanity;  acute  mania ;  alcoholic  insanity; 
impulsive  insanity ;  sometimes  in  imbecility;  some  cases  of  chronic 
mania ;  some  cases  of  senile  insanity ;  agitated  melancholia  ;  per- 
secutory monomania  ;  monomania  of  jealousy;  chronic  hysterical 
insanity;  outbursts  of,  in  expansive  syphilitic  insanity;  acute 
rheumatic  insanity;  traumatic  insanity;  some  cases  of  insanity  of 
myxoedema ;  insanity  with  ex-ophthalmic  goitre. 

Yisual  Hallucinations.— See  "  Hallucinations." 

Yocal  Cord  or  Cords  Paralysed.— Sometimes  in  confirmed  general 
paralysis. 

Yociferation,  Abusive.— In  maniacal  form  of  saturnine  insanity; 
expansive  syphilitic  insanity. 

Yoices.— See  "  Hallucinations  "  (auditory)  and  "  Hears  Voices." 

Voluntary  Movement,  Little  or  no — In  stuporous  melancholia. 

Yoracity — In  fully  developed  mania ;  confirmed  general  para- 
lysis ;  some  cases  of  terminal  dementia,  cretinism. 

Wander  Abroad,  Disposition  to.— Mania  errabunda.  In  moral  insan- 
ity; early  general  paralysis;  pubescent  insanity ;  early  monomania. 


48         INDEX   OF   SYMPTOMS   SOMATIC   AND   PSYCHICAL,    ETC. 

Weakness. — In  diabetic  insanity  ;  neurasthenia  and  neurasthenic 
insanity. 

Wealth,  Ideas  of. — In  most  cases  of  general  paralysis  ;  ambitious 
monomania ;  sometimes  in  acute  and  chronic  mania. 

Weeping. — In  melancholia ;  senile  melancholia  ;  chronic  alcoholic 
insanity;  motiveless  in  insanity  from  coarse  brain  disease  and  in 
general  paralysis ;  motiveless  and  alternating  with  laughter  in 
choreic  insanity;  in  climacteric  insanity,  especially  at  menstrual 
periods ;  tearless  in  some  cases  of  delirium  of  young  children ; 
frequent  fits  of,  in  agitated  melancholia. 

Weighing  Own  Judgments.— In  folie  clu  doute. 

Wet  in  Habits. — (a,)  From  inattention,  indifference,  perverseness,  or 
loss  of  sense  of  decency. — In  terminal  dementia  ;  idiocy;  puerperal 
insanity ;  acute  and  chronic  mania ;  third  stage  of  general  para- 
lysis, (b.)  From  unconsciousness. — In  anergic  stupor;  epileptic 
insanity  (in  fits,  etc.,  and  during  paroxysmal  excitement), 
(c,)  From  paralysis  or  atony  of  neck  of  bladder. — In  organic 
dementia ;  third  stage  of  general  paralysis;  terminal  dementia. 
(d,)  From  loss  of  nornml  feeling  of  discomfort  caused  by  full 
bladder. — In  terminal  dementia ;  melancholia ;  acute  delirium. 
(e,)  From  two  latter  combined. — In  terminal  dementia  ;  melancholia  ; 
acute  delirium  ;  senile  dementia. 

Wildness  and  Intractability. — In  epileptic  idiocy. 

Will,  Affections  of  the.— See  "Abulia"  and  "Hyperbulia."  Abulia 
in  neurasthenia. 

Words  and  Acts  (Own),  Paying  Extreme  Attention  to. — In  folie  du 
doute. 

Work,  Distaste  for. — In  organic  melancholia;  prodromal  symp- 
tom of  acute  delirium ;  often  prodromal  of  melancholia  ;  prodromal 
of  erotic  and  religious  forms  of  delusional  insanity  ;  in  neuras- 
thenic insanity. 

Wringing  Hands.— In  agitated  melancholia. 

Wrists  Flexed. — In  advanced  apathetic  terminal  dementia ; 
sometimes  in  saturnine  insanity,  paralytic  idiocy,  and  organic 
dementia. 

Write,  Inability  to.— See  "Loss  of  Ability  to  Write." 

Writing  Altered. — In  general  paralysis ;  acute  mania  ;  mania  with 
delusions;  alcoholic  insanity;  in  third  stage  of  general  paralysis 
it  becomes  shapeless  and  hieroglyphical. 


INDEX   OF   MENTAL   DISEASES,    ETC.  49 


CHAPTER  III. 

INDEX  OF  MENTAL  DISEASES,  WITH  THEIR  SYNONYMS 
AND  SYMPTOMS. 


ABDOMINAL    DISORDERS  (Insanity  from). 

See  "  Gastro-Enteric  Insanity "  (vSibbald)  in  section  on 
"Hypochondriacal  Melancholia."  Schroeder  van  der  Kolk 
describes  a  case  of  catarrh  of  the  bladder  with  great  dysuria 
and  at  times  complete  anuria,  in  which  mental  symptoms 
arose,  viz.,  "  Violent  nervous  symptoms,  hallucinations  of  hearing, 
and  subsequently  of  seeing  also  "  (Bucknill  and  Tuke,  "  Psycho- 
logical Medicine,"  p.  369).  "  Melancholia  is  the  form  of  mental 
disorder  which  we  most  frequently  witness  in  combination  with 
hepatic  derangement  of  a  chronic  character "  {op.  cit.  p.  370). 
(See  "Bright's  Disease,  Insanity  of.") 

ADOLESCENT    INSANITY. 

Clouston  ("Mental  Diseases,"  p.  534)  gives  the  period  of  its 
occurrence  as  being  that  between  the  ages  of  18  and  25,  notably 
between  20  and  25.  This  form  of  insanity  is  marked  by 
exaltation,  loquacity  and  restlessness,  sleeplessness,  anorexia, 
viciousness,  the  maniacal  period  being  sometimes  preceded  by  a 
stage  of  depression.  The  disease  is  marked  by  a  periodicity  and 
a  tendency  to  remission  recalling  a  similar  character  of  the  nisus 
generativus  in  both  sexes.  The  attacks  of  mania  seem  to  have 
a  special  relationship  to  the  function  of  reproduction  (Clouston, 
op.  cit.  p.  540).  Masturbation  or  illicit  sexual  intercourse  seems 
to  be  a  frequent  forerunner  or  concomitant,  or  both,  of  the 
derangement. 

Clouston  gives  the  characteristics  of  the  mania  of  this  form  of 
insanity  as :  (1,)  Very  acute  though  seldom  delirious ;  (2,)  Of 
short  duration,  patients  soon  apparently  recovering ;  (3,)  Con- 
stant tendency  to  relapses  ;  (4,)  Frequent  neurotic  heredity. 

4 


50  INDEX   OF  MENTAL   DISEASES, 

ANEMIC    INSANITY. 

This  mostly  takes  the  form  of  mild  melancholia,  sometimes 
with  an  element  of  stupor.  Occasionally  there  is  an  alternating 
acutely  maniacal  and  melancholic  condition  (Clouston,  "  Mental 
Diseases,"  p.  592). 

BRIGHT'S    DISEASE    (Insanity  of). 

This  is  met  with  in  chronic  Bright's  disease  with  contracted 
kidneys,  enlarged  heart,  and  dropsical  tendency. 

"  The  symptoms  present  are  mania  of  a  delirious  kind,  with 
extreme  restlessness,  delusions  as  to  persons  round  the  patient,  an 
absolute  want  of  fear  of  jumping  through  windows,  or  other 
actions  that  would  kill  or  injiire.  The  symptoms  are  character- 
ised by  remissions,  during  which  the  patient  is  quiet,  rather 
composed  in  mind  and  rational,  but  very  prostrate  in  body" 
(Clouston,  op.  cit.,  p.  596). 

CATALEPTIC     INSANITY. 

The  intellectual  faculties  of  cataleptic  patients  are  often  found 
far  from  sound.  The  intellect  is  narrow,  presents  lacunse, 
and  is  incapable  of  much  development. 

Frequently  the  psychical  troubles  amount  to  actual  insanity. 
In  the  mild  form  this  consists  of  a  more  or  less  considerable 
depression  of  the  faculties.  The  perceptions  still  exist,  but  they 
are  less  precise  than  in  the  normal  condition. 

In  a  more  severe  form  a  condition  of  stuporous  melancholia 
exists.  This  is  in  some  sort  a  semi-cataleptic  state  left  by  the 
cataleptic  attack,  and  which  persists  during  the  intervals.  The 
maniacal  or  expansive  form  is  very  rarely  observed. 

Finally,  in  the  most  severe  form  intelligence,  consciousness, 
and  memory  are  completely  abolished,  and  the  termination  is  per- 
manent dementia  (Bi-a,  "  Manuel  des  Maladies  Mentales,"  p,  93). 

CHOREIC    INSANITY. 

Not  to  be  confounded  with  choreomconia,  that  is,  the  Epidemic 
Dancing  Mania  of  the  middle  ages  (Spitzka,  Bucknill  and  Tuke, 
etc.).  Symptoms  of  choreic  insanity  (Bra,  "Man.  des  Mai. 
Ment.,"  p.  90,  et  seq.).  According  to  Marc6  there  are  in  the 
choreic  mental  state  four  elements,  sometimes  occurring  singly, 
generally  combined  :  (1,)  Troubles  of  moral  sensibility.  There  is 
a  change  of  character  betraying  itself  by  excessive  irritability, 
angry  outbursts,  inexplicable  oddity  of  behaviour,  rapidly  alter- 
nating, and  motiveless  laughing  and  weeping.  Sometimes  there 
is  a  melancholy  condition  with  a  feeling  of  anguish  and  anxiety; 
(2,)  Intellectual  disorders.      These  soon  appear.      The   memory 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  51 

first  fails.  The  patients  become  incapable  of  fixing  their  attention 
on  any  subject.  They  become  dull  and  indifferent.  At  the  same 
time  the  ideas  are  very  mobile  and  extremely  futile  ;  (3,)  Hallu- 
cinations are  very  frequent.  These  occur  on  awaking,  during 
dreams,  and  especially  in  the  state  intermediate  between  sleeping 
and  waking.  They  have  always  a  painful  and  terrifying  charac- 
ter. Often  solely  visual  (animals,  lights,  etc.),  sometimes  they 
are  auditory  (voices,  slamming  doors,  etc.),  olfactory  (odour  of  sul- 
phur, phosphorus,  etc.),  gustatory  (taste  of  poisoned  food,  etc.),  or 
even  tactile  (formication,  pricking,  etc.).  Hallucinations  are  most 
frequently  met  with  in  hysterical  chorea,  but  may  sometimes  accom- 
pany pure  chorea;  (4,)  Sometimes  maniacal  excitement  with  inco- 
herence and  hoarse  and  inarticulate  cries.  Under  the  influence  of 
the  visual  and  auditory  hallucinations  the  intellectual  faculties 
may  present  a  condition  amounting  to  actual  mania  which  in  half 
the  cases  is  rapidly  fatal,  death  being  preceded  by  formidable 
ataxic  disturbances.  Even  in  the  more  fortunate  cases  intellectual 
troubles  of  varying  dm-auon  often  remain. 

CIRCULAR     INSANITY     (FOLIE     CIRCULAIRE). 

It  most  often  begins  with  depression,  sometimes  with  a  mania- 
cal access  (Bra,  "Maladies  Mentales,"  p.  44).  Bra  describes 
three  varieties  : — 

(1,)  Folie  drculaire,  properly  so  called,  in  which  the  attacks  of 
excitement  and  depression  follow  each  other  without  interruption 
(Marc6). 

(2,)  Folie  alternante,  in  which  there  is  a  very  short  lucid  interval 
between  each  phase  (Falret). 

~  (3,)  Folie  d  cloiihle  forme,  in  which  the  attacks  of  mania  and 
melancholia  are  separated  by  an  interval  often  considerable 
(Baillarger).  Both  the  maniacal  and  melancholic  phases  of 
circular  insanity  are  characterised  by  the  absence  of  delusions  and 
by  the  complete  retention  of  consciousness  by  the  patient. 

In  the  maniacal  period  the  ideas  preserve  in  general  a  certain 
sequence.  There  is  not  the  incoherence  of  ordinary  mania. 
There  is  a  tendency  to  mockery,  to  complaint  making,  to  mis- 
chievousness,  to  be  epigrammatical.  The  patients  are  cunning 
and  fertile  in  expedients  of  every  sort.  A  patient,  a  typical  case 
of  folie  circulaire  at  Haydock  Asylum,  was  overheard  plotting 
with  another  patient  to  make  false  accusations  against  the  young 
and  new  nurses,  as  she  said  they  would  not  be  believed  if  they 
made  them  against  the  older  ones.  This  patient  was  highly 
educated  and  accomplished,  and  in  her  maniacal  periods  expressed 
herself  well  both  orally  and  in  her  letters  which  were  numerous 
and  voluminous.      She  belonged  to  a  good  family.      Speaking  of 


52  INDEX   OF   MENTAL  DISEASES, 

this  form  of  insanity  Clouston  ("  Mental  Diseases,"  p.  237)  says, 
"  Another  remarkable  fact  is  that  by  far  the  greater  number  of 
persons  who  suffered  from  it  were  persons  of  education,  and  far  more 
than  a  due  proportion  of  them  were  persons  of  old  families.  I 
never  met  with  a  fine  case  in  a  person  whose  own  brain  and  whose 
ancestors'  brains  had  been  uneducated."  A  physical  peculiarity 
about  the  patient  above  mentioned  was  that  she  possessed  a  well 
developed  moustache  and  beard. 

Bra  {op.  cit.,  p.  45)  says  some  patients  evince  the  possession  of 
grand  ideas,  set  numerous  projects  on  foot,  become  prodigal,  and 
make  purchases  in  all  directions.  In  the  melancholy  period,  on 
the  contrary,  the  same  patients  are  remarkable  for  their  sordid 
avarice. 

Sufferers  from  folie  circvQaire  are  remarkable  also  for  a  very 
great  tendency  to  alcoholic  excesses,  for  a  moral  perversion,  in 
fact,  leading  to  all  sorts  of  excesses.  Sometimes  there  is  sexual 
perversion  impelling  the  patients  to  make  advances  to  persons  of 
their  own  sex.  With  regard  to  the  trophic  disturbances,  the 
patients  become  thin  during  the  melancholy  phase  and  increase  in 
weight  during  the  maniacal.  Some  patients  suffer  from  a 
periodical  anguish,  an  intense  dyspnoea  presenting  some  analogy 
to  angina  pectoris  (Bra,  ojy.  cit.,  pp.  45-46).  Each  phase  may 
last  one,  two,  or  six  months  or  more.  They  are  sometimes 
regular  and  equal  in  length,  but  more  frequently  irregular 
(Clouston). 

Towards  the  end  of  the  attack,  maniacal  or  melancholic,  the 
patient .  wakes  up  as  if  from  a  dream  and  gradually  becomes 
possessed  of  his  or  her  mental  faculties  (Bra). 

"  The  order  of  each  cycle  varies  in  different  patients  ;  the 
mania  may  precede  the  melancholia  or  vice  versa.  Both  may 
be  of  a  mild  type,  and  both  may  be  very  severe ;  or  one  may 
be  slight  and  the  other  intense."  "As  a  rule  the  mania  and 
melancholia  correspond  to  each  other  in  intensity.  Where  the 
cycle  is  of  brief  duration,  lasting  a  few  days  or  weeks,  both  are 
apt  to  be  very  well  marked  ;  where  it  is  of  a  duration  of  months, 
l)oth  are  apt  to  be  of  a  mild  type "  (  Spitzka,  "  Insanity," 
p.  272). 

Clouston  (oj).  cit.,  p.  2.30)  only  found  one  or  two  cases  out 
of  forty  that  were  absolutely  regular.  He  says  (p.  236)  about  one 
half  of  his  cases  followed  a  more  or  less  regular  monthly  periodi- 
city. About  one-third  obeyed  the  law  of  seasonal  periodicity,  all 
in  an  irregular  way.  The  remaining  sixth  he  could  bring  under 
no  known  law  on  account  of  their  irregularity. 

The  cases  described  by  Clouston  (pp.  217-230)  correspond  to 
the  French  folie  alternante  and  folie  a  double  forme  in  most 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  53 

instances,  and  he  gives  the  order  of  the  phases  as  mania,  melan- 
cholia, sanity,  followed  again  by  the  same  cycle,  but  with  differing 
duration  of  the  component  parts  and  of  the  whole  cycle.  He 
states  (p.  236)  that  in  his  experience  at  least  90  per  cent,  of  the 
cases  begin  with  maniacal  exaltation. 

CLIMACTERIC     INSANITY. 

Symptoms. 

Incipient. — Loss  of  energy,  bodily  and  mental,  failure  of 
courage,  annoyance  at  trifles,  groundless  fears,  sleep  dreamy  and 
broken,  appetite  diminished,  bowels  costive,  complexion  less 
fresh,  skin  often  muddy  and  more  pigmented  than  usual,  patient 
dislikes  going  into  company,  symptoms  aggravated  at  menstrual 
periods ;  then  patient  apt  to  suffer  from  real  mental  depression, 
irritability  of  temper  and  sleeplessness ;  there  is  then  also  weeping 
(Clouston,  "  Mental  Diseases,"  pp.  -555-556). 

Developed  Stage. 

The  headaches,  giddiness,  flushings,  flashes  of  light,  etc., 
which  usually  precede  or  accompany  the  climacteric,  now 
disappear.  The  thinness,  flabbiness  of  muscle,  and  pigmentation 
of  incipient  stage  get  worse.  Frequently  there  are  skin  irritations, 
causing  picking  and  scratching  ;  constipation,  anorexia,  insomnia 
and  diminution  of  capacity  for  work ;  depression  more  real  and 
continuous  ;  morbid  apprehensiveness  ;  loss  of  self-control  or  fear 
of  the  loss  of  it ;  loss  of  natural  affection,  often  repugnance  to 
husband ;  vague  suicidal  impulses.  In  the  worst  cases  these 
suicidal  feelings  are  strong,  and  attempts  are  frequent  though 
generally  feeble.  Sometimes  there  are  impulses  to  injure  husband 
or  children.     Hallucinations  of  hearing  are  frequent. 

May  terminate  in  (1,)  Acute  excited  melancholia,  exhaustion, 
and  death;  in  (2,)  A  sort  of  shy  uselessness  or  "paralysis  of 
energy";  or  (3,)  In  complete  recovery. 

General  type  the  same  in  men  as  in  women.  Impairment 
of  spontaneity,  courage  and  energy.  Insomnia,  depression, 
restlessness,  hypochondriasis.  Loss  of  flesh.  Avoidance  of 
society.  There  may  be  suicidal  longings  and  desires  usually 
not  very  intense  (Clouston,  "Mental  Diseases,"  pp.  556-557 
and  560). 

Dr.  Merson's  groups  of  symptoms  of  climacteric  insanity 
("West  Riding  Medical  Reports,"  vol.  vi.,  1876) ;  (Bucknill  and 
Tuke's  "Psychological  Medicine,"  4th  ed.,  pp.  366-367)  :— 

(1,)  Cases  characterised  by  simple  depression  without  halluci- 
nations of  the  senses,  or  intellectual  derangement.      In  some. 


54  INDEX   OF   MENTAL   DISEASES, 

extreme  nervous  irritability  and  hypersesthesia  of  sensation, 
almost  amounting  to  hallucinations. 

(2,)  Depression  also  the  prevailing  condition,  but  along  with 
this  great  emotional  and  intellectual  disturbance,  hallucinations 
of  the  senses  not  uncommon,  and  some  vague  delusions  of  a 
depressing  kind  nearly  always  present. 

(3,)  Delusions  of  suspicion  and  persecution  the  most  prominent 
symptoms.  In  most  cases  hallucinations  of  the  senses  and  out- 
bursts of  excitement  not  unusual. 

"An  intense  craving  for  drink  may  be  the  prominent,  and 
perhaps  the  only  symptom  which  characterises  the  morbid  con- 
dition of  the  system"  (Bucknill  &  Tuke,  p.  366). 

Skae  considers  as  pathognomonic  of  this  form  of  insanity  both 
in  men  and  women,  "a  monomania  of  fear,  despondency,  remorse, 
hopelessness,  passing  occasionally  into  dementia"  (Bucknill  & 
Tuke,  loc.  cit.). 

COARSE    BRAIN    DISEASE    (Insanity  from). 

I.— Organic   Dementia  (Paralytic  Dementia),   (Paralytic 
Insanity,  Clouston). 

There  is  usually  paralysis  or  muscular  weakness,  and  often 
aphasia  at  some  period  of  the  illness.  Clouston  (p.  380)  says, 
"  Paralytic  Insanity,  or  Organic  Dementia,  is  that  form  of  mental 
distui-bance  that  accompanies  and  results  from  gross  brain  lesions, 
as  apoplexies,  ramollissements,  tumours,  atrophies,  and  chronic 
degenerations  of  the  brain."  Its  symptoms  vary  according  to  the 
position,  kind  and  intensity  of  the  pathological  process.  But  it 
is  typically  a  dementia,  an  enfeeblement,a  lessening  of  the  mental 
power  super-added  to  some  sort  of  motor  paralysis.  Along  with 
this  enfeeblement  there  may  be,  and  there  usually  is,  a  certain 
amount  of  depression  at  first,  folloAved  afterwards  by  a  mild 
exaltation  and  emotionalism  of  a  childish  kind,  this  gradually 
passing  off  and  lea-sang  the  patient,  if  he  lives  long  enough,  f orget- 
fid,  helpless,  and  torpid. 

(1,)  Form  associated  with  Apoplexy  or  FiamoUissement. — This 
is  the  most  typical  form,  and  follows  apoplexy  from  rupture  of  a 
blood  vessel  in  one  of  the  great  basal  ganglia,  or  supervenes  on 
embolism  or  thrombosis,  causing  local  starvation  of  brain  tissue 
and  ramollissement.  "  Motor  restlessness  is  a  special  character- 
istic of  the  worst  class  of  cases."  In  the  ordinary  hemiplegic 
cases  the  alteration  of  speech  is  the  most  characteristic  motor 
symptom,  "it  is  a  thick  articulation,  not  a  tremulous  speech." 
Every  word  is  imperfectly  pronounced,  and  not  merely  those  at 
the  end  of   a  sentence.     Before,  or  during  speech  the  labial  and 


WITH  THEIR   SYNONYMS   AND    SYMPTOMS.  55 

facial  muscles  do  not  quiver,  "though  the  tongue  usually  trem- 
bles when  put  out."  Where  there  are  apoplexies  or  similar 
lesions  of  the  convolutions  themselves,  the  speech  symptoms  are 
more  like  those  of  general  paralysis,  and  there  are  often  epilepti- 
form, epileptic  and  congestive  attacks.  Clouston  does  not  believe 
that  complete  aphasia  can  co-exist  with  perfect  integrity  of  the 
intellectual  faculties,  and  says  he  has  never  seen  such  co-existence. 
An  organic  dement  with  no  nervous  heredity  will  be  "calm, 
reasonable,  and  quite  manageable,  though  forgetful,  torpid,  and 
emotional,"  while  one  with  a  bad  nervous  heredity  will  become, 
under  the  same  conditions,  "  restless,  depressed,  noisy,  and 
sleepless."  Most  organic  dements  are  treated  at  home,  as  single 
cases,  or  in  workhouses ;  only  "  the  noisy,  the  restless  at  night, 
the  very  dirty,  the  troublesome  find  their  way  into  asylums, 
motor  restlessness  necessitating  special  nursing  and  special 
rooms." 

In  one  case,  E.  M.,  under  my  care  at  Haydock  Asylum,  there 
was  no  motor  paralysis,  except  some  indistinctness  of  articulation. 
Before  admission  there  was  a  history  of  a  fit,  described  in  the 
statement  as  epileptic.  On  admission,  sense  of  smell  feeble, 
vision  of  left  eye  defective.  The  patient  was  listless,  stupid, 
and  very  irascible.  After  death  there  was  found  a  large  patch 
of  softening  in  the  prefrontal  region  encroaching  on  the  third 
frontal  convolution  and  the  island  of  Reil  (left  side).  The  left 
anterior  cerebral  artery  was  much  diminished  in  calibre  as 
compared  with  the  right. 

In  another  case  in  which  there  was  softening  of  the  inferior 
surface  of  the  right  temporo-sphenoidal  lobe,  there  was  extreme 
dementia.  The  gait  was  somewhat  feeble,  and  both  legs  were 
emaciated  to  an  equal  extent,  and  were  equally  weak.  The 
patient  complained  of  an  itching  sensation  in  the  skin  of  the 
chest  and  abdomen  (a  symptom  mentioned  by  Charcot  as 
characteristic  of  softening  of  this  region). 

These  cases  are  given  because  they  are  exceptional,  and  some- 
what difficult  to  diagnose ;  the  most  common  motor  symptom  in 
organic  dementia  being  well  marked  hemiplegia. 

(2,)  Form  caused  hy  Brain  Tumours. — "Intense  cephalalgia  is 
undoubtedly  the  most  common  sensory  symptom."  Next  to  this, 
"optic  neuritis  and  blindness  are  the  most  common  symptoms." 
"The  motor  signs  are  paresis  and  paralysis  local  and  general, 
convulsions  local  and  general,  and  congestive  attacks." 

The  most  common  mental  symptoms  are,  "first,  irritability  and 
loss  of  self-control,  and  change  of  disposition;  then  depression, 
with  or  without  excitement ;  then  confusion,  loss  of  memory, 
muttering  to  self,  loss  of  interest  in  all  things,  perhaps  delirious 


56  INDEX   OF  aiENTAL  DISEASES, 

attacks ;    then   drowsy   half-consciousness,    ending    in    coma   and 
death." 

The  bodily  and  mental  symptoms  are  affected  by  the  kind 
position  and  mode  of  growth  of  the  tumoiu",  and  there  may  be  no 
symptoms  or  only  vague  ones.  Some  tumours  cause  direct  and 
reflex  brain  irritation ;  others  give  rise  to  destructive  lesions, 
especially  ramollissement  (Clouston,  p.  388). 

II. — Organic  Melancholia. 

Clouston  {op.  cit.,  p.  107)  says,  "In  some  of  these  cases  I  have 
seen  the  mental  symptoms  the  very  first  to  appear,  long  before  the 
paralysis  or  even  before  great  bodily  weakness  made  its  appearance. 
A  paralysis  of  the  sense  of  well-being  and  the  enjoyment  of  life, 
a  difficulty  in  coming  to  decisions,  a  loss  of  mental  energy,  an 
intolerance  of  the  usual  work  if  not  an  actual  incapacity  to  do  it 
well,  a  tendency  to  make  slight  mistakes  in  small  things,  a  loss  of 
memory  and  a  sub-acute  mental  pain,  I  have  seen  to  exist  for  two 
years  before  a  man  showed  any  diagnostic  signs  of  brain  ramollisse- 
ment or  tumour.  The  melancholia  is  usually  of  the  simple  type, 
seldom  assuming  the  excited,  delusional,  or  distinctly  suicidal 
form.  I  have  seen  it  of  the  hypochondriacal  kind  in  a  few  cases." 
In  a  case  reported  by  me  in  "Brain,"  1882,  depression  of 
spirits,  suicidal  tendency,  defective  memory  for  recent  events, 
complete  left  hemiplegia,  were  some  of  the  outward  and  visible 
signs  of  softening  affecting  the  cortex  of  portions  of  the  right 
frontal,  parietal,  and  temporo-sphenoidal  lobes,  and  adhesion  of 
the  arachnoid  over  the  occipital  lobe. 

CONFUSIONAL     INSANITY     (PRIMARY). 

Primary  Confusional  Insanity.      Acute  Confusional 
Insanity. 

Synonyms. — Hallucinatory  Delirium,   Hallucinatory  Psychoneu- 

rosis,    "Wahnsinn    (KrafFt-Ebing),    Acute    Primare    Verriicktheit 

(Westphal),     Hallucinatory     Confusion,     Mania     Hallucinatoria 

(Mendel),  Delusional  Stupor  (Nemngton),  Frenosi  Sensoria 

Acuta  (Morselli),  Paranoia  Psiconeurotica. 

Spitzka  (p.  161)  says,  "This  disorder  is  rare,  and  develops 
rapidly  on  a  basis  of  cerebral  exhaustion."  He  further  says, 
"  The  patients  suffering  from  this  psychosis,  after  a  rapid  rise  of 
their  symptoms  during  a  period  of  incubation  rarely  exceeding  a 
few  days,  present  hallucinations  and  delusions  of  a  varied  and 
contradictory  character.  The  delusions  resemble  those  of  mania, 
and  more  often  those  of  melancholia,  but  no  emotional  state  is 
associated  vnth  them.     The  patients  assert  in  the  same  breath 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  57 

that  their  property  is  being  stolen,  and  that  they  are  going  to 
take  part  in  some  great  state  affair." 

"  The  speech  in  confusional  insanity  is  characteristic,  although 
there  is  no  richness  of  ideation,  as  with  mania.  The  sentences 
are  left  uncompleted,  and  are  entirely  irrelevant  as  well  as 
incoherent." 

"Delusions  of  identity  are  very  common.  The  patients  believe 
they  are  not  in  the  same  place,  or  they  recognise  as  old 
acquaintances  persons  to  whom  these  bear  no  resemblance.  It  is 
noteworthy  that  a  large  number  of  the  patients  are  aware  that 
a  change  has  taken  place,  that  they  are  no  longer  their  former 
selves,  and  they  may  be  able  to  give — by  snatches,  it 
is  true — a  tolerably  fair  account  of  the  circumstances  pre- 
ceding the  outbreak  of  the  disease.  But  as  the  latter  develops, 
the  patients  cease  to  recognise  their  position,  or  to  complain  of 
the  "head  trouble,"  whose  existence  they  previously  admitted, 
and  at  most  they  speak  of  their  former  selves  in  the  third 
person,  or  manifest  a  confused  variety  of  double  consciousness. 
When  the  hallucinations,  as  is  frequently  the  case,  preponderate 
from  the  beginning,  the  disorder  we  have  here  considered  is 
termed  by  some  Acute  Hallucinatory  Confusion.  Recovery  is 
gradual,  the  patient  becoming  progressively  clearer ;  his  somatic 
complaints,  such  as  headache,  then  occupy  his  attention  more 
than  his  incoherently  recounted  delusive  troubles,  and  finally 
reason  is  entirely  restored.  In  only  a  small  proportion  of  cases 
does  the  insanity  remain  and  the  patient  become  permanently 
deteriorated,  his  disorder  appearing  as  a  form  of  chronic  con- 
fusional insanity." 

Krafft-Ebing  ("  Lehrbuch  der  Psychiatric,"  p.  396)  states  that 
insomnia  or  unrefreshing  sleep  with  frightful  and  terrifying 
dreams,  nervous  irritability,  feeling  of  oppression,  headache, 
vertigo,  irascibility,  and  confusion  of  ideas  are  constant  phenomena 
of  the  developing  psychosis.  When  the  disease  has  reached  its 
acme  there  are  illusions  and  hallucinations  of  all  the  senses, 
especially  in  acute  cases,  those  of  sight  predominating.  So  that 
consciousness  soon  becomes  seriously  blurred  ;  the  patients  are 
confused  and  have  no  idea  of  their  position. 

CONFUSIONAL    INSANITY    (CHRONIC). 

Chronic  Confusional  Insanity  (Spitzka). 

Synonym. — Chronic  Mania. 

Ordinarily  called  Chronic  Mania,  see  Spitzka,  "Insanity",  p.  102. 
Some  maniacs  and  melancholies  lose  their  characteristic  emotional 
state,  but  retain  their  delusions,  which  become  fixed,  though  not 


58  INDEX   OF   SIENTAL  DISEASES, 

truly  systematised  as  in  monomania  (delusional  insanity).  In  a 
small  proportion  of  acute  confusional  cases  the  insanity  remains, 
constituting  a  form  of  chronic  confusional  insanity.  The  delu- 
sions in  chronic  confusional  insanity  are  not  elaborate,  and  not 
defended  with  skill  and  a  show  of  judgment.  "The  delusions 
resemble  rmns  left  over  from  the  destruction  of  the  more 
elaborate  and  multitudinous  if  less  fixed  delusions  of  mania  and 
melancholia,  around  which  the  gathering  tide  of  a  slowly  pro- 
gressing dementia  rises  till  the  assertion  of  the  delusions  becomes 
a  mere  parrot-like  repetition,  and  is  finally  buried  under  the 
same  levelling  sea  of  dementia  which  closes  the  history  of  all 
these  primary  psychoses  entering  the  domain  of  the  secondary 
deteriorations. 

"  The  weakening  of  the  logical  power  and  the  memory  accounts 
for  the  frequent  observation  in  these  patients  of  a  change  in 
their  sense  of  identity." 

"  The  appetite  and  assimilation  as  well  as  the  sleep  become 
normal,  or  nearly  so,  and  not  unfrequently  the  patients  become 
very  stout." 

"While  the  general  nutrition  does  not  always  suffer  in  the 
terminal  deteriorations,  certain  trophic  disturbances  are  quite 
common.  Hsematoma  auris,  cutaneous  eruptions,  premature 
grayness,  and  fatty  and  fibrous  changes  of  the  blood  vessels  are 
frequent  accompaniments"  (Spitzka,  pp.  170-171). 

CONSECUTIVE     INSANITY. 

I. — Post  Febrile. 

Xasse's  classification  of  post-febrile  insanity  (Bucknill  &  Tuke, 
4th  edit.,  p.  371):  (1,)  The  immediate  result  of  the  fever 
itself ;  (2,)  Constituting  a  prolongation  of  the  delirium  when 
the  fever  has  subsided ;  (3,)  Arising  during  convalescence. 

The  last  class  being  more  especially  intended  by  the  term 
Post-Fehrile  Insanity.  Scarlatina,  small-pox,  typhus,  intermittent 
fever,  measles,  erysipelas,  the  acute  anginas,  cholera,  acute  rheu- 
matism, are  the  febrile  conditions  in  and  after  which  it  occurs 
most  frequently  (Griesinger,  "  Die  Pathologic  und  Therapie  der 
psychischen  Krankheiten,"  p.  186,  et  seq.  ;  Clouston,  p.  600). 

Symptoms  of  (1,)  and  (2,)  (Savage,  "Insanity  and  Allied  Neu- 
roses," p.  435): — "The  patient  passes  through  the  first  few  days  of 
febrile  disturbance  naturally,  then  becomes  sleepless,  chattering 
and  often  amorous  ;  refusal  of  food  is  very  common,  and  rapid  ex- 
haustion follows."  "After  the  mania  has  lasted  for  a  "S'ariable 
number  of  weeks,  depression  or  partial  dementia  is  well  marked, 
there  being  some  vague  dread  or  other  in  the  former  case,  and  in 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  59 

the  latter  listlessness  mth  loss  of  memory,  disregard  of  friends  and 
relations,  and  neglect  of  the  decencies  of  life  "  (Savage,  (yp.  cit., 
p.  436). 

Savage  states  ("Insanity,"  etc.,  p.  216)  that  he  has  often  met  with 
cases  following  fevers  in  which  loss  of  memory  was  the  most 
marked  evidence  of  weakness  of  intellect.  He  has  frequently  met 
with  patients  whose  memory  was  seriously  damaged  for  a  longer 
or  shorter  period  after  typhoid  fever.  jSTow  and  then  such  cases 
do  not  recover  but  pass  on  from  one  stage  to  another  till  they 
become  absolutely  and  hopelessly  weak-minded. 

The  same  result  may  follow  rheumatic  fever.  With  regard  to 
the  relation  of  certain  cases  of  insanity  to  intermittent  fever, 
G-riesinger  states  that  most  of  the  cases  occur  during  convalescence 
from,  or  even  several  months  after,  the  fever;  others  intermit  with 
the  paroxysms  of  the  fever ;  others  replace  them.  The  form  is 
mania  -with  delirium.     It  is  very  beneficially  influenced  by  quinine. 

Symptons  of  (3): — Prodromal. — irritability,  change  of  manner, 
perhaps  some  childishness  (Bucknill  and  Tuke,  4th  ed.,  p.  371). 
Fvlly  developed. — Many  cases  are  examples  of  melancholia  and 
mania.  Some  present  the  ordinary  features  of  delusion  of  perse- 
cution with  hallucinations  of  hearing  and  (not  so  frequently)  of 
sight.  Some  cases  pass  into  dementia,  not  complicated  with 
paralysis  (Bucknill  and  Tuke,  loc.  cit.).  See  above-mentioned 
forms  of  insanity.  Primary  Confusional  Insanity  is  sometimes 
developed  during  the  exhaustion  following  fevers. 

II. — Consecutive  to  Local  Inflammatory  Dseases. 

Pneumonia,  pleurisy.  Savage  thinks  it  does  not  essentially 
affect  the  form  of  insanity  whether  the  mental  disturbance  is  due 
to  the  above  diseases  or  to  rheumatic,  scarlet,  or  typhoid  fever 
(p.  436). 

Griesinger  ("  Die  Pathologie  und  Therapie  der  psychischen 
Krankheiten,"  4th  ed.,  p.  191,  et  seq.)  describes  two  cases  of 
pneumonic  insanity.  In  one  there  was  transient  mental  disorder 
of  a  delirious  nature  with  ringing  in  the  ears  and  vertigo.  In  the 
second  case  the  delirium  passed  into  acute  mania  with  slight  left 
facial  monoplegia.  Afterwards  there  were  visual  and  auditory 
hallucinations.  Then  profound  dementia  with  weakness  of  left 
side,  and  mydriasis.  The  dementia  diminished,  and  four  months 
after  admission  the  patient's  condition  was  simply  one  of  slight 
mental  weakness. 

CYANOSIS  FROM  BRONCHITIS,  CARDIAC  DISEASE  AND 
ASTHMA  (Insanitij  of). 
"  This  is  a  form  of  delirium,  with  confusion,  hallucinations  of 
sight,  sleeplessness,  sometimes  suicidal  impulses  and  vague  fears. 


60  INDEX  OF  JIENTAL   DISEASES, 

These  symptoms  are  usually  worst  at  night,  and  often  end  in 
mental  torpor  passing  into  coma.  It  is  more  commonly  seen  in 
persons  of  advanced  age  than  in  young  people  (Clouston,  p.  589). 

DELIRIUM,     ACUTE     (ACUTE     DELIRIUM). 

Synonyms. — Delirium  Grave   (Spitzka) ;  Grave  Delirium  ;    Acute 
Delirious  Mania ;  Typhomania  (Luther  Bell). 

PSYCHICAL    SYMPTOMS. 

Precursory  (not  always  present) ;  change  of  character,  lassitude, 
distaste  for  work,  an  indifference  more  and  more  pronounced 
to  the  patient's  previous  occupation,  then  loss  of  sleep, 
cephalalgia,  apprehensions,  presentiments  of  evil,  inquietude, 
distortion  of  surrounding  objects  and  persons.  Then  supervene 
ideas  of  persecution,  poisoning,  etc.,  with  a  train  of  hullucinations 
of  a  terrifying  nature,  blood,  flames,  corpses,  precipices,  etc. 

Psychical  Symptoms  of  Fully  Developed  Stage. 

Maniacal  excitement  which  is  violent  and  continuous  ;  all  the 
members  are  in  motion,  great  loquacity  with  the  most  absolute 
incoherence.  IncajDable  of  attention,  the  patient  flies  in  terror 
from  all  who  approach  him,  -vvill  hear  nothing,  and  defends  him- 
self ^Wth  energy.  All  his  acts  bear  the  stamp  of  fear,  and  are  de- 
termined by  terrifying  hallucinations. 

At  the  end  of  the  disease,  when  the  temperature  has  attained  its 
maximum,  the  maniacal  excitement  disappears,  giving  place  to 
depression  and  fatal  coma. 

PHYSICAL    SYMPTOMS. 

Face  pale,  of  an  earthy  hue,  the  malar  prominences  red,  the 
countenance  expressionless  and  resembling  that  of  a  drunken  man. 

The  pulse  is  frequent,  maj''  reach  L50  ;  it  is  small  and  irregular. 
The  temperatiu-e  oscillates  between  102°r.  and  104°F.  The 
tongue  is  black  and  dry,  the  teeth  and  lips  covered  with  sordes, 
the  breath  malodorous.  Great  thirst.  Obstinate  constipation. 
There  is  excessive  motor  agitation,  grinding  of  the  teeth,  cramps ; 
often  embarrassed  speech  and  exaggerated  reflexes. 

In  fatal  cases  all  these  symptoms  are  accentuated,  the  respira- 
tion becomes  panting,  the  temperature  rises  to  106*F.,  deglutition 
and  articulation  become  impossible,  diarrhoea  succeeds  the 
constipation  ;  finally  subsultus  tendinum  supervenes.  Among  the 
terminal  conditions  are  found  pulmonary  and  renal  congestions, 
ecchymoses  and  bedsores.  A  gradually  increasing  di'owsiness 
ends  in  the  extinction  of  life.  The  course  of  the  disease  is  not 
always  regular,  but  is  sometimes  marked  by  remissions  (Bra, 
"  Manuel  des  Maladies  Mentales,"  pp.  162-164). 


WITH  THEIR   SYNONYMS   AND   SYMPTOMS.  61 

DELUSIONAL     INSANITY. 

Synonyms. — Monomania  or  Monopsychosis  of  Clouston ;  Delu- 
sional Monomania  of  Spitzka  ;  Paranoia  of  Krafft-Ebing  ;  Partial 
Delirium,  of  Bra.  Primare  Verriicktheit  (Griesinger) ;  D6lire 
Partiel,  Delire  Systematise,  Folie  Systematise  (Morel) ;  Mono- 
manie  Intellectuelle  (Esquirol) ;  Paranoia  Universalis  (Arndt) ; 
Chronisclier  Wahnsinn  (Schiile) ;  Paranoia  Originaria 
Degenerativa   (Morselli). 

Five  Forms  :  (1,)  Persecutory  and  suspicious  ;  (2,)  Ambitious; 
(3,)  Religious  ;  (4,)  Erotic ;  (5,)  Jealous. 

PERIOD  OF  INCUBATION.  PERSECUTORY  (much  the 
most  common)  and  AMBITIOUS  FORMS.  (See  "  Delusions," 
Chapter  II.) 

Mental  inquietude  and  excitement.  The  ideas  are  mobile  and 
painful.  The  patient  takes  no  interest  in  anything  which  is  not 
connected  with  his  puerile  and  apparently  insignificant  pre- 
occupations. The  most  trivial  events  are  remarked  by  him 
and  assume  in  his  eyes  an  extraordinary  importance.  A  person 
who  turns  in  the  street,  who  sings,  coughs,  or  uses  his 
pocket-handkerchief  is  immediately  suspected  of  having  made 
a  sign  of  contempt,  or  having  so  acted  intentionally  to  give 
offence.  Or  in  the  ambitious  form  the  patient  fancies  the  passers- 
by  speak  of  him  as  some  great  personage  (Bra,  "  Manuel  des 
Maladies  Mentales,"  pp.  49  and  52). 

Spitzka  ("Insanity,"  pp.  301-302)  believes  that  although  mono- 
mania may  develop  after  any  deep  and  sudden  injury  to  the 
nervous  system,  yet  in  the  vast  majority  of  cases  it  is  based  on  an 
inherited  taint  of  insanity  or  on  a  transmitted  neurotic  vice,  and 
that  in  this  larger  number  of  cases  there  are  usually  noted  before 
the  actual  outbreak  of  the  disorder,  anomalies  of  character,  of  the 
general  nervous  functions,  and  of  the  somatic  constitution.  In  a 
form  of  monomania  depending  on  gross  structural  defect  and  named 
by  Sander  "Originare  Verriicktheit,"  and  by  Krafft-Ebing 
"  Originare  Paranoia "  (primitive  or  congenital  paranoia)  the 
subjects  are  noted  to  be  peculiar  from  infancy ;  they  entertain 
vague  aspirations,  are  excessively  egotistical,  and  the  non-recog- 
nition of  their  supposed  importance  or  abilities  leads  them  to 
consider  themselves  the  subject  of  persecution.  In  others  the 
egotism  is  so  great  that  the  most  ridiculous  failures  are  not 
capable  of  dispiriting  them,  but,  on  the  contrary,  are 
accepted  as  proofs  of  a  divine  mission  which  is  to  be  carried 
on  in  a  state  of  perpetual  martyrdom.  Hallucinations 
frequently  develop  as  the  disorder  progresses.  With  these 
there  are  symptoms  of  neural  disorder,  similar  to  those  found 


•62  INDEX   OF   iNIENTAL   DISEASES, 

in  imbecility  and  idiocy ;  some  have  epileptiform,  others 
choreiform,  and  still  others  quite  peculiar  and  indefinable  move- 
ments of  an  "  imperative  "  kind.  Peculiarities  in  pronunciation 
and  inability  to  pronounce  certain  consonants  in  childhood  have 
been  noticed  in  others.  There  are  in  addition  defects  in  the 
bodily  conformation  of  a  similar  kind,  although  usually  of  lesser 
degree  than  those  characterising  idiocy  and  imbecility  ;  the  head 
is  often  asymmetrical  or  deformed,  the  teeth  are  sometimes  badly 
developed,  and  there  may  be  club-foot,  strabismus,  or  atrophy  of 
one  side  of  the  body. 

PRODROMAL  STAGE,  RELIGIOUS  AND  EROTIC  FORMS. 

These  forms  rarely  commence  suddenly.  There  is  a  gradual  trans- 
formation of  the  individual  mostly  at  the  period  of  puberty.  The 
manifestation  of  mental  aberration  is  preceded  by  a  feeling  of  in- 
quietude, a  dislike  for  work,  a  profound  aversion  to  life  and  its 
enjoyments,  and  a  constant  pre-occupation  with  ideas  about  sin. 
The  patients  neglect  their  usual  duties  in  order  to  read  pious 
books  and  devote  themselves  to  religious  exercises.  To  these 
prodromata  are  added  sexual  excitement  and  erotic  ideas  ;  these 
latter  by  their  frequency  constitute  one  of  the  great  distinctive 
characters  of  religious  insanity  (Bra,  op.  cit.,  p.  56). 

I. — Persecutory  and  Suspicious  Form    (Monomania 
Persecutoria,  Delire  des  Persecutions). 

Fully  developed  stage.  This  is  by  far  the  most  common  form 
of  delusional  insanity  or  monomania.  The  delusion  or  delusions 
may  simply  arise  out  of  some  false  idea  accepted  without  dis- 
cussion or  out  of  false  sensations  (hallucinations). 

In  fully  developed  persecutory  delusional  insanity  the  delusions 
are  systematised.  Magnan  in  his  lectures  at  St.  Anne's,  speaks 
of  a  primary  period  of  uncertainty  and  restlessness,  and  a  second- 
ary one  of  systematised  delusion. 

Spitzka  (p.  313)  writes,  "Delusions  of  persecution  are  the  most 
common  ones  in  delusional  monomania.  There  is  a  marked 
difference  between  these  delusions  and  the  delusions  of  perse- 
cution found  in  melancholia.  While  the  melancholiac  believes 
that  he  is  pursued  or  punished  because  he  is  a  weak,  cowardly, 
bad,  or  criminal  person,  the  monomaniac  believes  that  he  is 
persecuted  from  motives  of  envy,  and  as  a  rule,  he  develops 
exalted  delusions  of  his  personal  importance  or  worth,  side  by 
side  with  those  of  persecution.'' 

The  most  common  delusions  are  that  certain  persons  are 
plotting  against  the  sufferer,  have  evil  designs  on  him,  annoy  him, 
poison  his  food,  or  persecute  him  in  some  way,  or  in  various  ways. 


WITH   THEIR   SYNONYMS    AND   SYMPTOMS.  63 

Auditory  Halkicinations. — These  are  generally  the  first  hallucina- 
tions to  show  themselves.  The  patient  hears  nicknames  and 
insulting  phrases,  at  first  in  a  low  voice,  afterwards  in  a  loud  one. 
The  voices  are  in  the  workshop  and  in  the  street,  especially  at 
night.  The  voices  come  from  all  directions,  from  people  passing 
in  the  street;  and  indoors,  from  the  chimney,  the  keyhole,  the 
ceiling,  the  walls,  the  floor. 

Olfactory  Hallucinations  are  less  common  than  those  of  hearing. 
The  patient  perceives  disagreeable  or  disgusting  odours. 

Gustatory  Hallucinations  are  common.  The  food  tastes  badly, 
hence  arises  the  delusion  that  it  is  poisoned. 

Cutaneous  Hallucinations  generally  accompany  the  auditory  ;  they 
seldom  appear  alone  (Bra,  p.  51).  The  patients  feel  itchings, 
formications,  sensations  of  heat  which  they  attribute  to  magnetism, 
electricity,  etc. 

Visceral  Hallucinations  or  Illusions. — The  patients  fancy  that 
people  tear  out  their  li^'er,  heart,  or  testicles. 

Sexual  Hallucinations  or  Illusions. — People  cause  the  suff"erers  to 
feel  voluptuous  sensations,  or  practise  masturbation  on  them. 
These  symptoms  may  be  unilateral. 

Visual  Hallucinations  are  rare  and  even  denied  by  some  authors. 

The  patient  is  at  first  astonished  at  the  persecutions  and  wonders 
why  he  is  subjected  to  them.  By  degrees  the  vague  feeling 
disappears,  and  having  discovered  his  supposed  enemies,  the 
patient  either  (1,)  flies  or  hides  from  them  ;  (2,)  commits  suicide  ; 
or  (3,)  acts  strongly  on  the  defensive  and  offensive  (Bra,  op.  cit. 
p.  52). 

II. — Ambitious  Form  (Ambitious  Monomania  (Esquirol) ; 
Megalomania). 

This  may  succeed  the  persecutory  form  or  develop  during  it, 
the  patient  thinking  he  must  be  of  consequence  to  attract  so  much 
attention. 

It  may  precede  the  persecutory  form,  the  latter  becoming 
developed  owing  to  the  patient's  extravagant  claims  not  being 
recognised.  It  may  develop  primarily,  but  most  frequently  it 
follows  auditory  hallucinations.  Thus  a  patient  had  heard  voices 
which  said,  "There  is  the  king  of  France,"  and  he  became  Henri 
de  Bourbon  (Magnan,  Bra,  loc.  cit.). 

These  patients  are  the  emperors,  kings,  queens,  princes,  dukes, 
lords,  generals,  and  colonels  of  asylums. 

The  delusions  in  ambitious  delusional  insanity  are  systematised ; 
they  are  distinct  and  fixed,  and  the  patient  can  reason  logically  with 
regard  to  them  though  his  arguments  are  based  on  false  premises. 
The  patients  also  speak,  act,  and  dress,  if  permitted,  conformably 


64  INDEX   OF  MENTAL   DISEASES, 

as  they  believe,  to  the  character  they  represent.     They  will  Avear 
straw  crowns,  tin  medals,  and  hoop-iron  swords.     One  patient,  a 

farmer,  called  himself  "Captain  A of  the  sappers  and  miners," 

and  talked  about  his   "  sweetheart,  Victoria,"  to  see  whom  he 
walked  all  the  way  from  the  North  of  England  to  Windsor. 

III. — Religious  Form  (Theomania). 

Developed  Stage. — Religious  monomania. — (1,)  Expansive, 
characterised  by  ambitious  ideas  and  egotism.  The  patients 
believe  themselves  to  be  prophets,  apostles,  the  Messiah,  etc.  They 
have  a  mission  to  save  society,  and  to  wrest  it  from  its 
iniquity.  They  dress,  speak,  and  act  accordingly  ;  visual  halluci- 
nations, and  more  rarely  auditory  and  gustatory  soon  appear. 
They  see  angels,  hear  the  voice  of  G-od,  and  perceive  intoxicating 
odours.  They  may  commit  self-mutilation,  suicide,  arson, 
assassination. 

(2,)  Depressive. — The  patients  accuse  themselves  of  having 
committed  all  sorts  of  crimes,  theft,  adultery,  murder,  abominable 
acts  :  of  being  the  cause  of  all  the  evil  in  the  world.  Others 
believe  themselves  possessed  of  the  devil.  They  evince  impulses 
to  mutilation,  suicide,  and  homicide ;  hallucinations  are  rare. 
(Bra,  oj?.  cit.,  pp.  57-60).  Sexual  ideas  and  delusions  founded  on 
them  are  very  common  in  religious  delusional  insanity. 

IV. — Erotic  Form  (Erotomania). 

Developed  Stage. — The  patient,  most  frequently  a  female, 
evinces  a  platonic  affection  for  some  person  of  the  opposite  sex 
(a  clergyman,  a  doctor,  a  person  in  authority),  and  connected 
with  this  becomes  possessed  of  delusions. 

Acting  on  these,  the  patient  writes  to  the  object  of  her  affections 
(who  may  be  married),  follows  him  about,  tries  to  reside  in  the 
house  with  him,  and  accuses  others  of  preventing  this  object  being 
accomplished.  A  patient  at  Haydock  Lodge  had  thus  acted  with 
regard  to  a  curate  previously  to  admission,  and  afterwards  trans- 
ferred her  affections  to  one  of  the  doctors  of  the  asylum.  When  in 
private  care  after  leaving  the  asylum,  she  escaped  and  travelled 
many  miles  to  see  the  doctor.  In  all  other  respects  the  patient 
was  quite  rational,  though  quarrelsome  and  somewhat  egotistical, 
and  ambitious.  Physically,  she  was  dwarfed  and  deformed. 
This  form  would  include  the  so-called  Ovarian,  or  Old  Maids' 
insanity  of  Skae,  described  by  Clouston  ("Mental  Diseases,"  p.  478). 

Spitzka  ("Insanity,"  p.  27)  says,  "  Systematised  delusions  of 
an  erotic  character  are  found  as  the  leading  symptoms  of  the  so- 
called  'Erotomania.'  This  perversion  is  not  necessarily  accom- 
panied by  animal  sexual  desire,  and  the  adjective  erotic  is  here 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  65 

used  in  its  classical  sense.  The  patient,  noted  in  his  adolescence 
for  his  romantic  tendencies,  construes  an  ideal  of  the  other  sex 
in  his  day  dreams,  and  subsequently  discovers  the  incorporation 
of  this  ideal  in  some  actual  or  imaginary  personage,  usually  in  a 
more  exalted  social  circle  than  his  own.     He  then  spins  out  a 

perfect  romance expansive  or  depressive  delusions  are 

incorporated  vdth  the  erotic  ones.     As  a  rule,  the  affection  for 

the  adored  object  remains  as  chaste  and  pure  as  it  begins 

hallucinations  are  woven  into  the  delusive  conception,  which 
consequently  assumes  such  a  predominating  position  in  the 
patient's  mental  horizon,  as  to  entirely  overshadow  it." 

V. — Jealous  Form. 

Savage  ("Insanity,"  etc.,  p.  263)  speaks  of  this  as  a  "dangerous 
and  troublesome  form  of  delusional  insanity."  There  is  a  fixed 
delusion  that  the  husband  or  wife,  as  the  case  may  be,  of  the 
patient,  is  unfaithful,  and  the  most  trivial  occurrences  are  taken  as 
proof  of  his  or  her  guilt.  This  delusion  leads  to  constant 
annoyance,  threats,  and  violence.  Of  several  cases  of  this  nature 
at  Haydock  Asylum,  one  manifested  some  weakness  of  the  limbs 
of  one  side. 

DEMENTIA,  TERMINAL   (TERMINAL  DEMENTIA). 

Synonyms. — Secondary  Dementia    (many  authors) ;    Terminaler 
Blodsinn  (KrafFt-Ebing). 

The  mental  defect  in  terminal  dementia  may  vary  from  a 
mere  loss  of  memory,  usually  of  recent  events,  to  the  nearly 
complete  extinction  of  mind  (Spitzka,  p.  169).  When  the  patient 
becomes  calmer  and  stouter,  without  real  mental  improvement, 
dementia  is  to  be  feared  (Bucknill  and  Tuke,  p.  183). 

In  the  severe  forms  of  terminal  dementia,  the  patient  cannot 
answer  questions  however  simple;  in  the  mild  forms  he  may  be 
able  to  answer  questions,  but  cannot  sustain  a  conversation.  The 
power  of  calculation  is  diminished  or  lost,  and  the  memory", 
especially  for  recent  evenrs,  is  defective  to  a  pathological  extent ; 
e.g.,  the  patient  cannot  remember  the  year,  the  month,  or  the  day  of 
the  week ;  cannot  remember  his  own  age,  and  if  told  his  age,  cannot 
calculate  the  year  of  his  birth.  Forgets  what  he  says  immediately 
after  he  has  said  it,  and  cannot  tell  Avhat  he  had  for  his  last  meal. 
Has  no  idea  of  place  or  time  ;  does  not  know  where  he  is  or  how 
long  he  has  been  there. 

May  be  (1,)  agitated,  or  (2,)  apathetic  (KrafFt-Ebing,  Spitzka). 

(1,)  Of  the  Agitated  or  Active  Form. — This  form  of  terminal 
dementia,  succeeds  chronic  mania,  and  agitated  melancholia ;  the 
patients  are  restless  and  talkative,  and  even  obtrusive  or  destruc- 


66  INDEX   OF  MENTAL  DISEASES, 

tive.  SjDeech  and  acts  are  disconnected  and  senseless.  Fragments 
of  delusions  are  retained.  There  is  frequently  a  change  in  the 
patient's  sense  of  identity,  in  consecjuence  of  weakening  of  the 
logical  power  and  memory.  This  form  of  terminal  dementia  is 
progressive  and  of  longer  duration  than  the  apathetic  (Spitzka, 
p.  170). 

(2,)  Of  the  Apathetic  Form. — This  form  of  dementia  is  a  sequel  of 
anergic  stupor,  stuporous  melancholia,  and  violent  outbreaks  of 
maniacal  fiiror  (Spitzka,  jd.  168).  Countenance  expression- 
less. Extensors  not  innervated,  and  flexors,  therefore,  predominate. 
Some  patients  have  to  be  dressed,  undressed  and  fed.  Others  are 
docile  and  assist  the  attendants  in  various  ways.  Others  lounge 
listlessly  about,  sit  or  stand  in  one  place  all  day,  performing 
rhythmical  movements,  or  vociferating  some  set  phrases  (Spitzka, 
pp.  168-169). 

Some  dements  are  "wet"  and  "dirty"  from  loss  of  the  sense  of 
decency ;  others  simplj^  from  loss  of  the  normal  feeling  of  discom- 
fort caused  by  a  full  bladder  and  loaded  rectum,  or  from  muscular 
weakness,  or  both  the  latter  combined.  Some  have  to  be  fed 
forcibly,  others  eat  automatically,  and  others  have  ravenous 
appetites.  In  all  there  is  more  or  less  loss  of  memory  of  recent 
events.  Old  recollections  may  be  retained,  but  new  impressions 
cannot  be  registered  (Spitzka,  p.  169). 

DEPRIYATION  OF  SENSES  (Insanity  from). 

Clouston  (p.  603)  mentions  a  case  in  which  a  patient  became 
melancholic  and  suicidal  coincidently  with  loss  of  sight  from 
cataract,  and  improved  greatly  after  a  partially  successful 
operation. 

"It  is  very  common  indeed  for  those  who  are  deaf  to  become 
quiet,  depressed,  and  irritable.  It  is  also  common  for  such  persons 
to  become  subject  to  hallucinations  of  hearing,  and  so  insane  as 
to  need  to  be  sent  to  asylums." 

DIABETIC  INSANITY. 

Clouston  describes  two  cases,  and  summarises  as  folloAvs  {op.  cit., 
p.  595) :  "  They  were  both  melancholic.  They  both  imagined 
they  had  no  money  and  were  ruined,  and  could  not  j)ay  their 
debts.  They  both  had  a  disinclination  to  take  food.  They  both 
wanted  in  affection  for  their  children.  They  both  were  thin  and 
weak.  They  both  had  a  tendency  to  sores  on  extremities,  with 
small  healing  power ;  but  the  one  was  more  resistiA^e  and  dogged, 
the  other  more  passive,  inattentive,  and  utterly  uninterested  in 
anything  in  the  world.  Death  in  both  cases  occurred  rather 
suddenly." 


WITH  THEIR   SYNONYMS   AND   SYMPTOMS.  67 

Savage,  in  a  paper  read  before  the  Medical  Society  of  London 
("Lancet,"  Nov.  29, 1890),  stated  that  diabetes  and  insanity  alter- 
nate in  families  (one  generation  being  diabetic,  and  the  next  insane 
or  vice  versa) ;  and  also  in  individuals,  acute  diabetes  being  replaced 
by  acute  melancholia,  this  latter  giving  place  again  to  diabetes, 
which  was  again  replaced  by  temporary  mental  depression.  In 
two  cases,  elderly  men  (diabetic),  became  melancholic  shortly 
before  the  fatal  termination,  and  the  sugar  disappeared.  Besides 
patients  mth  diabetic  relatives,  Savage  had  ten  patients  in 
Bethlem,  who  were  both  insane  and  diabetic.  "  Nearly  all  the 
cases  with  diabetes  and  insanity  were  melancholic." 

EPILEPTIC  INSANITY. 

Synonyms. —Folie    epileptique,    Epileptisches    irresein,    Pazzia 

epilettica. 

Mental  State  of  Epileptics  not  Actaallij  Insane. — They  are 
irritable,  irascible  and  lazy.  They  are  often  dipsomaniacal, 
and  in  general  erotic.  They  are  mostly  gloomy,  morose,  taciturn, 
dreamy,  and  cowardly.  Some  are  extremely  docile  and  suave, 
servile  and  obsequious,  speak  with  facility,  and  have  a  habit, 
peculiar  to  themselves,  of  talking  quite  close  to  the  face  of  the 
person  with  whom  they  are  conversing.  All  epileptics  pass 
rapidly  from  anger  to  suavity ;  mobility  is  the  dominant  note  of 
their  character  (Bra,  "Manuel  de  Maladies  Mentales,"  pp.  73-74). 

Epileptic  insanity  (fully  developed)  may  be  divided  into  acute 
and  chronic. 

Acute  Epileptic  Insanity. 

The  three  principal  characteristics  of  acute  epileptic  insanity 
are :  (1,)  Impulsive  acts.  These  are  sudden,  brusque,  automatic,  and 
may  express  themselves  in  the  form  of  crimes  and  misdemeanours, 
I'.g.,  murders,  suicides,  assaults,  indecent  exposures,  etc.,  etc. 
They  may,  or  may  not  be  preceded  by  an  aura.  Huchard  records 
a  case  in  which  an  epileptic  called  out,  "Mother,  run  away,  I 
must  kill  you  ! "  (Bra,  p.  79) ;  (2,)  Loss  of  memory.  This  is 
generally  absolute,  but  occasionally  the  patient  may  have  a  vague 
recollection  of  what  has  happened;  (3,)  The  resemblance  to  each 
other  of  all  the  attacks  in  the  same  patient  (Huchard,  Legrand 
du  Saulle  ;  Bra,  p.  79).  This  form  may  precede  or  follow  the 
attack,  may  occur  in  the  intervals  between  the  convulsive  crises, 
or  may  even  replace  the  latter  : — 

(1,)  Before  the  Convulsive  Attack. — Prodomal  symptoms :  Various 
aurge,  e.g.,  the  sensation  of  cold  air,  of  tickling,  or  of  swelling, 
palpitations,  anorexia,  painful  trembling  of  certain  muscles,  formi- 
cation, gyratory  impulses,  cursatory  impulses ;  the  patients  throw 


68  INDEX   OF   MENTAL   DISEASES, 

themselves  forwards  or  backwards,  or  turn  on  their  own  axes. 
At  other  times  these  symptoms  are  accompanied  or  are  replaced 
by  an  intellectual  aiua.  Some  patients  suffer  from  insomnia, 
become  irascible,  have  suicidal  ideas  or  a  presentiment  of  the 
attack  ;  sometimes  on  the  contrary  they  possess  great  serenity  of 
mind. 

Developed  attack  :  Hallucinations  of  all  the  senses  frequently 
occur,  those  of  sight  being  most  common.  Some  epileptics 
jDerceive  sweet  tastes  and  strong  odours.  These  patients  under 
the  influence  of  their  hallucinations,  suddenly  commit  insensate 
acts  of  which  they  retain  not  the  slightest  recollection.  One  will 
upset  everything  in  his  neighbourhood,  and  then  fall;  another 
■sWU  take  up  a  glass  and  fling  it  to  a  distance ;  others  pronounce 
inconsequent  words,  or  are  seized  with  an  access  of  sudden 
rage. 

(2,)  Fost-Convuhive,  Acute  Epileptic  Iiisanitij. — More  common 
than  the  ante-convulsive  form.  Bra  describes  two  foi-ms  (p.  77) : 
(a,)  The  "petit  mal  intellectuel " ;  (h,)  The  "grand  mal 
intellectuel "  (Epileptic  mania  or  epileptic  furor).  The  intellectual 
petit  mal  occurs  most  frequently  between  the  ages  of  eighteen 
and  twenty.  There  are  three  distinct  A'-arities  (Bra,  loc.  cit.),  viz. : 
(a,)  The  Dejrressive,  characterised  by  hebetude,  confusion  of  ideas, 
profound  malaise,  extreme  prostration,  inquietude,  and  a  sensible 
loss  of  memory;  (/3,)  The  jExpansive,  ^Yiih.  cerebral  excitement, 
loquacity,  ideas  of  satisfaction,  bursts  of  laughter,  fits  of  gaiety, 
a  passion  for  travel  and  long  excursions,  and  an  incessant  desire 
for  change  of  place ;  (7.)  The  Mixed,  in  which  the  epileptic  fits, 
as  Billod  has  observed,  are  preceded  by  a  melancholy  state,  and 
followed  by  a  maniacal  one.  Finally,  a  soi't  of  persecutory 
maniacal  variety  has  been  observed,  in  which  the  patients  believe 
themselves  surrounded  by  enemies,  and  commit  crimes  under  the 
influence  of  these  ideas.  The  intellectual  grand  mal  (epileptic 
mania)  (epileptic  furor),  most  frequently  commences  suddenly. 
It  is  a  fui'ious  and  Adolent  outburst  of  maniacal  form,  with  blind 
impulses  to  destruction,  murder,  incendiarism,  etc.  Threats, 
complaints,  and  blasjDhemies  are  uttered  in  quick  succession  ;  the 
muscular  force  is  increased,  and  the  gestures  are  violent. 
Epileptic  maniacs  destroy  automatically,  and  stop  at  nothing. 
AfterAvards  they  preserA'e  in  general  no  recollection  of  what  they 
haA'e  done. 

(3,)  Attacks  of  Insanity  may  occui'  betAveen  the  epileptic  attacks 
(intervallary,  Spitzka),  or  eA^en  in  the  total  absence  of  couAoilsive 
seiziu-es ;  they  may  precede  the  latter  by  a  long  period,  and 
themselves  constitute  the  epilepsy.  This  is  the  "  Epilepsie  Larvee," 
of  French  authors.     In  it  the  mental  symptoms  constitute  the 


WITH  THEIR   SYNONYMS   AND   SYMPTOMS.  69 

sole  epileptic  manifestation.  In  these  cases,  periodical  excitement 
is  followed  by  prostration  and  stujDor ;  there  is  excessive  irascibil- 
ity, acts  are  commited  suddenly,  and  apparently  as  the  result 
of  irresistible  impulses ;  there  is  a  tendency  to  homicide  and  to 
suicide,  or  the  patients  may  suffer  from  terror-inspiring  halluci- 
nations (Grasset;  Bra,  "Maimel  des  Maladies  Mentales,"  p.  78). 
A  form  of  epilepsy  called  Epileptic  Vertigo,  is  characterised  by 
a  temporary  absence  or  short  eclipse  of  reason.  The  patients 
commit  unconscious  acts,  e.g.,  indecent  exposure,  micturating  in 
public,  making  incoherent  speeches,  etc.,  etc.  These  are  according 
to  Herpin,  veritable  fits  of  automatism,  and  of  somnambulism. 
These  attacks  are  characterised  by  their  suddenness,  and  by  the 
loss  of  memory  experienced  by  the  patient  of  what  has  occurred 
during  them  (Legrand  du  Saulle,  Trousseau,  Lasegue,  Magnan  ; 
Bra,  ''Maladies  Mentales,"  p.  76). 

Chronic  Epileptic  Insanity,  or  Epileptic  Dementia. 

This  is  a  consequence  of  repeated  attacks  of  acute  epileptic 
insanity,  or  of  epileptic  fits,  continued  through  a  succession  of 
years.  It  is  manifested  by  a  diminution  of  memory  and  of  power 
of  attention.  The  patients  forget  everything,  and  become  childish 
in  their  actions.  They  become  furiously  addicted  to  onanism  (Bra, 
"Manuel  des  Maladies  Mentales,"  p.  80).  The  special  sense 
reactions  are  a,bnormally  slow  in  epileptic  insanity  (Lewis). 

EXOPHTHALMIC  GOITRE  {Imanitij  idtli). 

The  chief  characteristics  of  a  typical  case  described  by  Savage 
(p.  413)  were  excitement,  incoherent  talking,  violence,  destructive- 
ness,  and  sleeplessness.  Afterwards  she  was  filthily  dirty  in  her 
habits.     Became  dull  and  sleepy  before  death. 

The  principal  symptoms  of  Graves'  disease  (Basedow's  disease) 
may  be  divided  into  :  (1,)  The  glandular,  enlargement  of  the 
thyroid  ;  (2,)  The  circulatory,  palpitation  of  the  heart  and  rapid 
pulse;  (3,)  The  ophthalmic,  exophthalmos  and  proptosis;  (4,) 
The  nervous,  tremor  and  insomnia;  (5,)  The  electric,  diminished 
electrical  resistance.  The  latter  has  been  demonstrated  in  many 
cases  at  the  Golden  Square  Throat  Hospital,  by  Wolfenden.  All 
the  symptoms  may  not  be  present  at  first  in  any  given  case. 

Savage  says  (p.  415),  "Besides  ordinary  insanity  associated  with 
this  condition,  I  have  met  with  several  cases  of  general  paralysis." 
He  further  observes  that  in  some  cases  of  recurrent  mental  dis- 
order, prominence  of  the  eyes,  rapid  pulse,  and  a  somewhat 
enlarged  neck  Avere  among  the  earliest  symptoms  of  the 
recurrence. 


70  INDEX   OF   MENTAL   DISEASES, 

FOLIE    A    DEUX. 

Synonjmi. — Folie  Communique. 

(1,)  Folie  imj)os6e,  in  which  weak-minded  patients  acquire 
delusions  from  stronger-minded  ones,  generally  monomaniacs  (see 
"  Delusions,  Sj)urious  "),  but  do  not  suffer  from  hallucinations. 

(2,)  "When  two  or  more  people  living  together  drift  simul- 
taneously into  the  same  form  of  insanit}^,  such  cases  are  called  by 
the  French  alienists  cases  of  Folie  simuUane'e  ;  but  (3,)  when,  as  is 
sometimes  the  case  in  folie  a  deux,  insanity  is  acquired  by  one  person 
and  then  from  him  by  another,  it  is  caAXcd  folie  communique  (Ireland, 
"  The  Blot  upon  the  Brain,"  p.  201,  et  seq.) ;  (Maraud  on  de  Monty  el, 
"Rev.  in  Allg.  Zeit.  f.  Psych.,"  1881.) 

FOLIE  DU  DOUTE  (DOUBTING  INSANITY). 

Synonyms. — Geistestorung  durch  Zwangsvorstellungen ;  Abortive 

Verrucktheit ;  Pseudomonomanie  ;  Paranoia  Eudimentaria 
Ideativa  (Morselli). 

The  patients  attacked  by  this  form  of  mental  disorder  generally 
belong  to  the  better  classes  of  society,  and  are  rarely  found  in 
public  asylums. 

At  first  the  jDatient  is  gloomy,  timid,  dreamy,  and  punctilious. 
He  loses  self-confidence,  reads  and  re-reads  what  he  writes,  pays 
extreme  attention  to  his  Avords  and  acts,  weighs  his  judgments, 
repeats  constantly  to  himself  the  same  words,  and  is  always  in- 
terrogating himself.  He  becomes  possessed  by  a  certain  idea  -or 
set  of  ideas,  and  around  this  his  intellectual  operations  concen- 
trate themselves. 

According  to  Legrand  du  Saulle  the  subjects  which  most 
frequently  form  the  pabulum  for  this  psychological  rumination  are : 
God,  the  l)irth  of  Christ,  the  creation,  nature,  the  virgin,  life,  the 
human  intellect,  the  sun,  the  moon,  the  stars,  thunder,  the  differ- 
ence of  the  sexes,  the  conformation  of  the  genital  organs, 
copulation,  sleep,  sudden  death,  j)recipices,  the  forgiveness  of 
sins,  omissions  at  confession,  the  size  of  animals,  the  dimensions 
of  objects ;  glass,  gold,  silver  and  copper  money,  rabid  dogs,  pins, 
door  latches,  paj^er  or  pencils. 

According  to  Ball,  in  a  general  manner  these  patients  may  be 
divided  into  five  categories,  viz. — The  metaphysical,  the  realistic, 
the  scrupulous,  the  timid,  the  counters  or  reckoners,  or  enumera- 
tors, to  which  may  be  added  those  affected  with  the  touch  craze 
(dilire  du  toucher)  :  (1,)  The  metajAysical  patients  are  always  de- 
manding the  why  and  the  how  concerning  the  most  inexplicable 
things,  the  creation,  God,  man,  the  external  world  and  their 
origin  and  destination;  (2,)  The. recdists  limit  themselves  totri^dal 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  71 

questions,  the  dimensions  of  an  object,  the  height  of  a  person,  etc. ; 
(3,)  The  scrupulous  ones  pass  their  lives  in  the  incessant  fear  of 
not  having  told  the  truth,  of  having  had  bad  thoughts,  of  having 
wronged  others,  etc.;  (4,)  The  timid,  when  they  -write  a  letter, 
read  it  several  times  to  be  sure  there  are  no  mistakes  ;  if  they 
shut  a  door  they  return  four  or  five  times  to  be  certain  that  they 
have  not  left  it  open  ;  if  they  take  a  carriage  they  search  the 
cushions  and  pockets  minutely ;  if  they  go  out  they  are  always 
afraid  of  seeing  somebody  fall  out  of  a  window,  etc.,  etc. ;  (5,) 
The  counters  enumerate  all  the  objects  they  see,  buttons  on  coats, 
l)ooks  in  a  library,  windows  of  houses,  trees  in  the  boulevards,  etc. ; 
(6,)  Those  who  suffer  from  the  touch  craze  (cUlire  du  toucher)  have 
a  constant  fear  of  having  touched  some  object" which  was  dirty 
(mysophobia)  or  contained  poison,  or  even  of  contaminating 
others  by  touching  them  ;  hence  result  incessant  ablutions  which 
never  in  the  patient's  opinion  produce  perfect  cleanliness.  Then 
there  are  other  forms  in  which  the  sufferers  doubt  the  existence 
of  themselves  or  of  the  external  world ;  others,  again  (somewhat 
resembling  agoraphobia)  in  Avhich  the  patient  cannot  pass  a  tree 
or  even  cross  the  doorstep. 

At  first  the  patients  are  conscious  of  their  condition,  say  their 
fears  are  absurd,  but  that  they  cannot  divest  themselves  of  them. 
They  have  an  irresistible  desire  to  be  reassured,  and  select  some 
friend  or  physician  of  whom  they  incessantly  ask  the  same 
questions  (Bra,  "Manuel  des  Maladies  Mentales,"  pp.  62-67). 
Krafft-Ebing  (p.  529)  considers  folie  du  doute  to  be  a  form  of  mental 
degeneration  developing  on  a  neurasthenic  basis. 

GENERAL     PARALYSIS   OF   THE    INSANE. 

Synonyms. — Paretic  Dementia  (Spitzka),  General  Paresis,  Diffuse 
Interstitial  Periencephalitis  ;  Dementia  Paralytica  (Krafft-Ebing)  ; 
Periencephalo-Meningitis  Diffusa  Chronica  (Calmeil);  Paralysie 
generale  des  Ali^nes,  Paralysie  generale  progressive,  Folie  para- 
lytique  ;  Paralyse  der  Irren,  Allgemeine  Paralyse  der  Geistesk- 
ranken,  Paralytischer  Blodsinn  ;  Paralytic  Dementia,  Progressive 
General  Paresis  ;  Psicopatia  paralitica  (Morselli). 

SYMPTOMS— PRODEOMAL. 
I. — Physical  or  Somatic. 
Neuralgia,  either  («,)  general,  characterised  by  its  mobility, 
flying  from  the  trunk  to  the  lower  extremities,  or  (6,)  localised, 
alfecting  a  single  nervous  branch.  The  most  frequent  forms  are 
sincipital ;  temporo-frontal  and  occipital ;  then  follow  cardialgia, 
epigastralgia,  and  rachialgia.  There  are  besides  various  painful 
sensations,  of   heat,  of  cold,  of  pressure,  etc.     There  are  often 


72  INDEX   OF   MENTAL   DISEASES, 

complaints  of  formication  and  pricking  sensations  in  the  skin; 
sensations  of  electric  currents  in  the  head.  Some  individuals  feel 
themselves  as  light  as  birds,  and  have  a  desire  to  walk  a  great 
deal ;  others  are  dull,  heavy,  fatigued,  and  are  not  relieved  by 
rest  in  bed.  The  eyes  are  often  injected  and  the  glance  unusually 
vivacious.  There  may  be  hummings,  whistlings,  sounds  of  bells 
in  the  ears,  vertigo  and  temporary  losses  of  consciousness 
("absences"  or  "stunnings"). 

The  principal  circulatory  troubles  are  palpitations,  flashes  of 
heat  to  the  head,  sudden  redness  of  the  face. 

There  are  often  disturbances  of  the  functions  of  the  digestive 
organs,  anorexia,  eructations,  constipation. 

Dysmenorrhoea,  and  amenorrhoea  are  often  noticed,  the  latter 
more  frequently  than  the  former  (Voisin,  "Traite  de  la  Paralj^sie 
G6n6rale  des  Alienee,"  pp.  6-8). 

Julius  Mickle  ("General  Paralysis  of  the  Insane,"  1st  ed.,  p.  4) 
says,  "Some  embarrassment  of  speech  is  occasionally  the  very 
first  sign  noticed,  and  Austin,  on  the  authority  of  Phillips, 
speaks  of  extreme  contraction  of  the  pupils,  and,  on  his  own 
authority,  of  a  fixed  or  unsymmetrical  condition  of  the  pupils  as 
being  frequently  prodromal ;  whereas,  Griesinger  observes  that 
the  pupils  are  sometimes  irregular  for  years  before  the  onset  of 
the  disease ;  while  trembling  of  the  limbs  has  been  placed  in  the 
same  heralding  category."  In  his  2ncl  ed.  Mickle  lays  stress  on 
epileptifoi-m  and  apoplectiform  seizures  as  forerunners  of  general 
paralysis. 

II. — Psychical  or  Mental. 

(1,)  Absence  or  diminution  of  sleep  at  night  is  very  frequent; 
what  sleep  is  obtained  is  disturbed  by  dreams  and  nightmares, 
and  is  only  very  slightly  refreshing.  At  the  same  time  there  is 
a  tendency  to  sleep  after  food ;  (2,)  A  change  of  character  and  of 
habits  is  always  observed ;  this  may  be  simply  an  exaggeration  of 
the  patient's  previous  tendencies,  or  it  may  be  a  completely  new 
and  opposite  character.  There  are  three  varieties  of  this  change : 
(ft,)  Depressive,  (b,)  Expansive,  (c,)  Demented.  The  first  variety 
is  the  most  frequent,  and  Doutrebente  says  that  it  appears  to  be 
constant.  Lasegue  also  says  that  sadness  opens  the  march  of  the 
disease  (Voisin,  "Paralysie  G6n(^rale,"  pp.  8--10).  In  the  de- 
pressive variety  the  patient  becomes  sombre,  sad,  melancholy ; 
in  the  expansive,  gay,  enterprising,  loquacious,  perhaps  witty, 
foolishly  confidential,  putting  the  world  au  coiumnt  with  his  pro- 
jects and  ideas,  satisfied  with  everything,  starting  ambitious 
projects  which  fail ;  (3,)  Change  in  the  affections,  persons  pre- 
viously dear  to  the  patient  become  hateful  to  him  ;  (4,)  Unusual 
and  useless  activity  ;  (-5,)  Change  of  occupation ;  (6,)  Frequently 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  73 

excess  in  eating  and  drinking;  (7,)  Sexual  excesses  in  sonae  cases; 
(8,)  Extraordinary  egotism,  often  revolting  ;  (9,)  Inconsistencies 
in  speech  and  acts,  generosity,  just  debts  being  unpaid,  selling 
necessary  articles  to  buy  unnecessary  ones ;  sordid  avarice  ac- 
companied hy  a  habit  of  purchasing  articles  of  secondary  utility  ; 
(10,)  Thefts  are  frequently  committed  in  the  demented  or 
debilitated  form  ;  (11,)  Loss  of  memory  for  recent  events  is  the 
first  failing  ;  proper  names  are  early  forgotten  ;  the  speech  is 
slow,  wrong  words  are  used  unconsciously  ;  instead  of  names,  sub- 
stitutes as  "thingumy,"  "Avhat  do  you  call  it,"  "what's  his  name," 
etc.,  are  employed;  sentences  are  broken  off  abruptly  ;  (12,)  The 
attention  in  the  debilitated  or  demented  form  cannot  be  suffici- 
ently fixed;  when  the  patients  write  they  leave  out  letters  and 
words;  they  cannot  continue  steadily  at  any  occupation;  they 
cannot  manage  household  affairs  or  business  so  well  as  formerly ; 
some  calculate  badly  and  give  \^^:ong  change  ;  reasoning  power 
and  judgment  are  also  v/eakened  (Voisin,  "Trait6  de  la  Paralysie 
Generale  des  Alienes,"  1879,  pp.  10-18). 

Savage  ("Brit.  Med.  Jour.,"  Apr.  5,  1890)  gives  as  "warnings" 
of  general  paralysis,  muscular  fatigue,  ataxic  symptoms,  temporary 
aphasia,  change  in  hanchvriting  with  difficulty  or  fatigue  in 
■s^^:iting■ ;  alteration  of  facial  expression,  the  lines  of  the  face  being- 
wiped  out  and  giving  rise  to  an  appearance  of  fatness ;  ptosis,  and 
external  strabismus;  slight  attacks  of  giddiness,  or  loss  of  power, 
temporary  loss  of  sight  or  of  feeling  (so  called  slight  "fainting- 
fits"), epileptiform  fits  (if  epileptic  or  epileptiform  fits  occur  at 
irregular  intervals  in  a  middle-aged  man,  mental  changes  such  as 
loss  of  memory  occurring  with  each  fit  and  expression  being  jDer- 
manently  affected,  general  paralysis  is  almost  certainly  present). 
Such  fits  may  precede  the  ordinary  symptoms  of  general  paralysis 
by  several  years. 

Headache,  facial  neuralgia,  other  forms  of  neuralgia,  headache, 
accompanied  by  tenderness  or  feeling  of  lightness  in  the  head, 
sciatica  (double,  with  change  in  habits,  etc.,  not  to  be  forgotten), 
rheumatic  pains,  temporary  loss  of  sight,  optic  neuritis,  affections 
of  hearing,  alterations  in  the  senses  of  taste  and  smell,  defect  of 
colour  perception  in  artists,  loss  of  the  finer  relations  of  time  in 
musicians. 

Loss  of  power  of  social  accommodation,  memory  for  recent 
events  and  for  engagements  defective  (especially  if  any  fainting 
or  other  fits  have  occurred),  loss  of  power  of  attention,  want  of 
persistence,  restlessness,  motor  or  mental.  In  cases  where  the 
mind  suffers  before  the  body,  the  above  intellectual  defects  nearly 
all  occur  in  greater  or  less  degree. 

Moral  weaknesses  or  faults;  stupid  stealing,  and  thoughtless 


74  INDEX    OF   MENTAL   DISEASES, 

indecency  (exposure  of  the  person  being  more  frequent  than 
assaults). 

Instability;  tremor  of  the  finer  muscles,  uncertainty  of  gait, 
and  tendency  to  fall ;  restlessness,  endless  things  being  started  and 
set  aside  on  the  first  fresh  suggestion;  almost  always  abnormal 
reaction  to  alcohol  or  drugs,  the  patient  being  very  easily  intoxi- 
cated or  poisoned. 

Change  of  temper  and  character  are  probably  the  most  constant 
symptoms  of  early  general  paralysis.  Change  of  character  with 
instability  of  purpose  and  some  motor  weakness  occurring  in  a 
middle-aged  man  almost  always  point  to  general  paralysis. 

Hypochondriasis  may  be  one  of  the  warnings;  alternations  of 
buoyancy  and  depression  ;  marked  hysterical  or  hystero-epileptic 
fits  in  middle-aged  men  are  even  more  alarming  than  epileptic 
fits. 

Sudden  outbreak  of  mania  is  a  frequent  precursor  of  general 
paralysis.  General  paralysis  may  quickly  succeed  an  attack  of 
acute  delirium  (acute  delirious  mania,  grave  delirium,  "  brain 
fever"). 

In  addition  there  are  vaso-motor  troul)les,  with  a  history  of 
syphilis  or  brain  injury.  Take  note  of  early  fatigue,  fainting  or 
other  fits,  loss  of  smell,  vague  optic  disc  changes,  unaccountable 
knee  phenomena,  unusiial  headaches,  neuralgia  and  sciatica, 
change  of  character,  progressive  loss  of  the  highest  control,  moral 
lapses  and  instabilit}'  in  various  forms. 

INTERMEDIATE    STAGE. 

When  thei-e  are  mental  symptoms  wthout  certain  diagnostic 
somatic  characteristics. 

This  period  is  often  absent.  It  sometimes  commences 
bx'usquely  without  a  previous  prodromal  period.  Or  it  may  com- 
mence insidiously.  It  may  be  said  to  liaA'e  commenced  when  the 
mental  trouble  of  the  prodromal  period  has  Ijecome  sufficiently 
marked  to  merit  the  name  of  insanity.  This  mental  condition 
may  resemble  :  (1,)  Melancholia  with  stupor  ;  stuporous  melan- 
cholia, melancholia  attonita  ;  (2,)  Hypochondriacal  melancholia  ; 
(3,)  Lypemania  (melancholia)  ;  (4,)  Mania  ;  (5,)  Folie  circulaire. 

It  may  consist  of  modifications  of  the  sentiments  and 
instincts. 

Exaggeration  of  the  altruistic  sentiments  and  intellectual 
debility  may  be  observed  at  this  period. 

Voisin  (p.  21)  fixes  the  maximum  limit  of  this  period  at  two 
years,  and  says  if  somatic  symptoms  appear  after  a  longer  period 
of  mental  aberration  than  this,  we  have  had  to  do  in  the  first 
instance  with  some  form  of  simple  insanity.     He  says,  however, 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  75 

that  a  remission  lasting  two  years  may  occur  between  the  subsi- 
dence of  the  mental  symptoms  and  the  commencement  of  the 
somatic  troubles. 

CONFIRMED  GENERAL  PARALYSIS. 
First    Stage  —  SoaiATic    Troubles. 

The  five  most  valuable  signs,  because  the  most  constant,  ordin- 
arily the  earliest,  and  the  most  persistent,  are:  (1,)  Loss,  or 
diminution  of  the  sense  of  smell  on  one  or  both  sides  (Voisin, 
p.  39).  Mickle  ("GeneraL  Paralysis,"  1st  ed.,  p.  16)  states  that 
his  experience  does  not  agree  with  that  of  Voisin  as  to  the  loss  of 
smell,  but  he  admits  that  hallucinations  of  smell  are  very 
I'are  in  general  paralysis  ("  comparatively  infrequent  ")  (2nd  ed., 
p.  21) ;  Griesinger  says  (p.  404)  that  after  the  disease  has  lasted 
a  long  time,  and  only  then,  the  senses  of  smell  and  taste  become 
blunted  so  that,  for  example,  wine  can  not  be  distinguished 
from  water;  (2,)  Febrillary  tremors  of  the  muscles  of  the  face, 
lips,  and  tongue.  Griesinger  ("Path.  u.  Therap.  Psych. 
Krank.,"  4th  ed.,  p.  402)  says,  "The  Tongue  is  always  the  organ 
whose  movements  first  present  irregularity.  The  patient 
commences  to  speak  with  difficulty,  to  articulate  somewhat 
inaccurately,  and  to  stammer.  The  tongue,  when  protruded, 
does  not  incline  to  one  side,  but  tremulous  and  occasionally 
convulsive  movements  *of  it  are  observed";  (.3,)  Tremulousness 
of  speech  ;  (4,)  Inequality,  excessive  dilatation,  excessive  con- 
traction, want  of  mobility  of  the  pupils  ;  (5,)  Fever  with  special 
characters,  i.e.,  it  occurs  every  eight,  ten,  or  fifteen  days,  suddenly, 
lasts  one  or  several  days,  is  of  low  range,  higher  in  the  evening, 
and  disappears  as  suddenly  as  it  comes. 

The  Accessory  signs  are  : — 

I. — Sensory.  Anaesthesia  (cutaneous)  occurs  often  at  the  com- 
mencement ;  hyperaesthesia,  temporary,  quite  at  commencement 
of  disease. 

Griesinger  (op.  cit.,  p.  404)  states  that  cutaneous  Sciisibiiity 
is  blunted  in  all  cases  at  the  commencement,  and  in  some  cases 
afterwards  abolished,  and  that  occasionally  there  occur  transitory 
states  of  extreme  hypersesthesia  in  which  the  slightest  touch 
excites  the  most  extended  reflex  movements,  convulsions  of  all 
the  voluntary  muscles. 

Pains,  often  like  neuralgic  pains  of  the  trunk  and  limbs ; 
sometimes  vague.  The  pains  generally  disappear  when  the 
disease  becomes  pronounced. 

The  muscular  sense,  the  heat  sense,  and  the  electric  sensibility 
may  be  abolished,  or  over-excited,  altered  or  hallucinated. 


76  INDEX   OF  MENTAL   DISEASES, 

Visual  acuteness  may  diminisli  to  the  extent  of  blindness. 
There  may  be  visual  hallucinations  and  illusions. 

Hyperacousia  sometimes  occurs  and  auditory  hallucinations  are 
frequent  and  tumultuous. 

All  these  sensory  troubles  included  in  the  accessory  signs  are 
common  to  the  intermediate  and  the  true  first  period. 

II. — Motor.  Temporary  paralytic  attacks  lasting  from  several 
hours  to  several  days.  Persistent  attacks  which  may  be  (1,) 
General ;  (2,)  Incomplete ;  or  (3,)  Progressive.  The  gait  is 
peculiar  in  consequence,  the  legs  are  widely  sepai-ated,  the  toes 
turned  out,  and  the  tread  heavy,  the  patient  stumbling  and 
tripping. 

Griesinger  {op.  cit.  p.  402)  says,  "At  the  same  time  that  the 
speech  becomes  difficult,  more  frequently  not  until  soon  after, 
a  change  in  the  gait  of  the  patient  is  observed ;  he  does  not  lift 
his  legs  properly,  Avalks  stiffly,  involuntarily  deviates  to  one  side 
when  attempting  to  walk  straight  forward,  and  easily  stuml^les  if 
the  ground  be  at  all  uneven — for  example,  when  going  over  a  step." 

The  physiognomy  is  expressionless  ;  the  eyebrows  are  raised 
up  on  the  forehead  towards  the  middle  of  their  arch,  or  fall  over 
the  eyes  like  a  moustache.  The  generalised  paralysis  is  rare  at 
the  commencement  of  the  disease,  so  also  is  the  unilateral.  The 
latter  is  most  conspicuous  wben  the  patient  walks,  by  the  lateral 
inclination  of  the  body,  and  by  the  elevation  of  the  opposite 
shoulder.  On  the  side  of  the  low  shoulder  will  be  generally 
noticed  a  slight  deviation  of  the  facial  traits ;  the  furroAvs  are  less 
marked,  the  eye  is  less  open,  the  labial  commissure  is  lowered,  the 
tongue  is  protruded  to  the  weak  side,  and  the  uvula  deviates.  This 
unilateral  paralysis  is  genei'ally  temporary. 

Ptosis  sometimes  occurs  ;  exophthalmia  and  external  strabismus 
are  not  frequent,  but  are  sometimes  met  combined.  Internal 
strabismus  has  been  observed  at  the  beginning  of  the  disease. 

Paralysis  of  one  or  more,  rarely  of  both,  vocal  cords  sometimes 
occurs ;  constipation  arising  from  the  muscular  weakness  is 
frequent. 

Tremors  of  the  lower  and  upper  extremities,  ataxic  in  nature. 
Manual  inabilit}^,  leading  to  awkwardness  in  delicate  manipula- 
tions and  to  alterations  in  AATiting,  the  letters  being  smaller  and 
less  regidar.  With  regard  to  the  lower  limbs  the  patient  can  stand 
steadily  but  Avalks  too  rapidly ;  attempted  movements  are  over 
done  or  insufficiently  done. 

Champing  of  jaws,  with  movements  of  mastication  ;  rigidity  of 
the  trunk  muscles ;  gTinding  of  the  teeth.  The  first  of  these 
three  symptoms  belongs  rather  to  the  second  stage,  the  other  two 
to  the  first  (Voisin,  op.  rif.,  p.  62). 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  77 

III. — Modifications  in  the  character  of  the  pulse.  Compressible 
under  the  finger.  The  tracings  show  a  certain  elevation  of  the 
ascending  line  ;  the  frequent  presence  of  a  plateau,  oscillations  in 
the  line  of  descent,  and  a  variable  degree  of  dicrotism.  As  the 
disease  progxesses  this  condition  becomes  accentuated. 

IV. — Modifications  of  the  Urine.  Density  increased,  more  or 
less,  either  during  depression  or  during  excitement.  Quantity  of 
urine  augmented.  The  quantity  of  urea  is  generally  augmented, 
and  that  of  the  chlorides  and  phosphates  diminished  (Voisin, 
op.  cit.,  p.  64). 

CONFIRMED    GENERAL    PARALYSIS. 
First    Stage — Psychical    Troubles. 

These  are  only  the  exaggeration  of  those  which  are  met  ^\'iih 
during  the  prodromal  and  intermediate  periods.  Most  frequently 
there  is  mental  aberration,  although  occasionally  there  is  only 
enfeeblement  of  the  intellectual  faculties  accompanied  by  a  per- 
version of  the  sentiments. 

When  there  is  mental  aberration  it  has  always  special 
characters  ;  the  ideas  are  multiple,  mobile,  absurd,  and  contra- 
dictory ;  the  mental  state  may  be  expansive  or  def)ressive,  the 
former  being  much  more  frequent. 

In  the  expansive  form  there  are  :  (1,)  Ideas  of  satisfaction ;  (2,) 
Ideas  of  grandeur,  differing  sensibly  from  those  of  other  megalo- 
maniacs ;  (3,)  Ideas  of  wealth;  (4,)  Ideas  of  exaggeration;  (5,) 
Ambitious  ideas  (second  and  third)  combined  with  hypochondria- 
cal ideas,  giving  rise  to  very  odd  conceptions. 

The  depressive  form  may  take  the  guise  of  lypemania  or  of 
hypochondria. 

The  lypemania  may  assume  :  (1,)  The  form  of  melancholia 
agitata;  (2,)  Of  stuporous  melancholia;  (3,)  Of  religious  mel- 
ancholia; (4,)  Of  persecutory  delusional  insanity;  (5,)  Of 
delusions  of  poverty. 

The  hypochondriacal  mental  aberration  may  be  sub-divided 
into  :  (1,)  Delusions  concerning  obstruction  of  organs  ;  (2,)  De- 
lusions of  negation  of  existence  ;  (3,)  Micromaniacal,  the  patients 
believing  themselves  to  be  little  infants  or  dwarfs. 

The  hypochondriacal  aberration  has  characters  which  are  only 
exceptionally  met  with  outside  general  paralysis ;  e.  g.,  it  appears 
suddenly,  it  is  exceedingly  absurd,  it  is  mobile.  When  the 
intellectual  trouble  takes  the  foi-m  of  dementia,  this  may  vary 
from  slight  loss  of  memory  for  recent  events  (hardly  perceptible 
to  strangers)  to  dementia  closely  approaching  stupor. 

Whatever  the  intellectual  troubles  may  be,  there  are  simul- 
taneously modifications  in  the  sentiments  and  the  instincts,  and 


78  INDEX   OF   MENTAL   DISEASES, 

the  actions  are  stamped  mth  a  character  of  improvidence  and 
absurdity  (Voisin,  op.  cit.,  pp.  68-108). 

CONFIRMED    GENERAL    PARALYSIS. 

Second   Stage. 

Any  one  of  the  accessory  signs  may  now  acquire  major  import- 
ance. Various  affections  of  sensibilit/j  and  of  the  organs  of  sense  are 
observable,  anaesthesia,  hypersesthesia,  weakness  of  sight  with  few 
hallucinations,  abolition  of  smell  and  taste.  Tortuosity  of  retinal 
arteries.  The  patients  eat  in  a  disgusting  manner,  swallow  without 
discrimination,  eat  with,  voracity,  and  do  not  masticate  sufficiently, 
so  that  they  are  often  choked.  Hemiplegia  is  rare,  and  in 
general  the  muscular  force  is  preserved. 

There  are  phenomena  of  vaso-motor  paralysis,  flushings  of  the 
face,  and  the  pupillary  phenomena.  (See  "  Somatic  symptoms," 
1st  Period.) 

The  patient  requires  assistance  in  walking,  dressing  and  eating. 
He  cannot  turn  round  without  staggering  or  even  falling. 

The  ataxi/  differs  from  that  of  tabes  dorsalis ;  it  is  not  increased 
by  closing  the  eyes.  There  are  trenujvs ;  silent  agitation.  The 
speech  is  slow,  drawling,  hesitant  from  the  cerebral  lesions  ;  stam- 
mering, stuttering,  and  tremulous  from  the  bulbar.  There  may  be 
also  mutism.  The  writing  is  irregular  and  shaky.  The  lingual 
tremors  become  more  and  more  accentuated ;  the  other  first 
period  symptoms  continue.  There  may  be  fever  slight  and  con- 
tinuous, or  sharper  and  temporary. 

The  mental  aberration  may  be  expansive  or  depressive,  or 
often  both  combined ;  may  be  hypochondriacal.  The  ideas 
become  more  and  more  absurd,  and  less  and  less  numerous  and 
mobile.  There  may  be  dementia  Avithout  delusions,  and  then  the 
course  is  slow. 

The  affective  sentiments  become  enfeebled,  and  finally  abol- 
ished. The  instincts  lose  their  vivacity,  and  the  sexual  appetite 
is  lost  never  to  return  (Voisin,  op.  cit.,  pp.  109-143). 

CONFIRMED    GENERAL    PARALYSIS. 
Third   Stage. 

(1,)  Cutaneous  Ancesthesia. — Sometimes  so  complete  that  the 
patient  can  be  burnt  without  feeling  it. 

(2,)  The  organs  of  sense. — Very  variable.  In  some  cases  optic 
nerve  atrophy  has  been  observed,  but  the  most  frequent  lesion 
seems  to  be  tortuosity  of  the  retinal  arteries  (Voisin  and 
Galezowski). 

(3,)  Ataxia. — In  some  cases  the  patient  can  neither  walk  nor 
stand.     The  tongue  is  protruded  and  withdrawn  with  difficulty. 


WITH   THEIR    SYNONYMS   AND   SYMPTOMS.  79 

The  speech  becomes  more  and  more  hesitant  and  tremulous  until 
it  becomes  unintelligible,  and  the  patient  speaks  very  little. 
Sometimes  complete  mutism  supervenes,  either  on  account  of 
extreme  ataxy  of  the  muscles,  or  complete  abolition  of  the 
intellectual  faculties,  or  degeneration  of  the  lingual  muscles. 
The  writing  is  absolutely  shapeless  and  hieroglyphical. 

(4,)  Farahjsis. — Formerly  a23parent,  now  becomes  real.  May 
be  general  or  unilateral ;  more  frequently  the  latter.  The  patient 
becomes  first  wet  and  then  dirti/  in  consequence  of  dementia 
rather  than  paralysis.  But  a  temporary  congestive  flushing  of 
the  face  is  often  accompanied  by  incontinence  of  urine  OAving  to 
paralysis  of  the  vesical  sphincter. 

(5,)  Muscular  Contract^ires. — In  general  paralysis  without  com- 
plications these  are  not  persistent ;  they  may  last  a  day  or  a 
week,  and  then  disappear  from  day  to  day. 

(6,)  Fsi/chical  Troubles. — The  delusional  condition  has  generally 
subsided  into  dementia,  and  when  it  does  persist  it  takes  the 
character  of  the  depressive  as  often  as  that  of  the  ambitious  form ; 
these  may  replace  each  other  from  day  to  day,  or  even  be 
simultaneous.  The  patients  mutter  such  words  as  millions, 
jewels,  castles,  etc.  Coquetry  persists  to  the  end  with  the 
females,  whereas  the  males  make  use  of  such  words  as  emperor, 
king,  etc.  Anything  bright  attracts  the  patients,  and  they  collect 
pieces  of  rubbish  under  the  delusion  that  they  are  jewels,  gold, 
etc.  The  memory  is  entirely  lost,  both  for  recent  and  long  past 
events,  so  that  the  patients  forget  even  the  meal  times,  though 
they  remain  very  greedy  and  very  voracious. 

(7,)  Affective  Sentiments. — These  have  entirely  or  almost  entirely 
disappeared.  Or  occasionally  there  may  be  unaccountable  anti- 
pathies. 

(8,)  Cachexia. — This  is  manifested  by  a  dull  tint  of  the  skin 
which  becomes  dry,  desquamates  furfuraceously,  or  becomes 
greasy  and  emits  a  repulsive,  acrid,  ammoniacal  characteristic 
odour.  The  hair  falls.  If  the  patient  is  not  well  nursed  he 
becomes  affected  with  impetigo,  and  with  pediculi  capitis  and 
corporis.  The  temperature  is  subnormal.  The  arterial  diastole 
is  hardly  perceptible.     The  urine  is  often  foetid. 

(9,)  Trophic  disturbances. — Bedsores ;  these  will  sometimes  heal 
in  one  situation  whilst  they  are  forming  in  another. 

(10,)  Alterations  in  the  blood. — It  is  fluid,  viscous,  does  not 
coagulate,  or  coagulates  with  difficulty  ;  the  clot  which  floats  in  a 
brownish  serosity  is  soft,  diffluent,  and  tears  readily.  A^oisin  has 
discovered  in  some  cases  bacteria  and  vibriones  {op.  cit.,  p.  161). 
There  will  sometimes  be  found  angular  globules  and  crystals 
of    urate   of   soda.      The   alterations   of    the    blood    may   also 


80  INDEX   OF  MENTAL   DISEASES, 

be  observed  in  other  lunatics  who  have  fallen  into  a  cachectic 
state. 

(11,)  Othceimttomata. — More  frequent  in  the  second  and  third 
stages  of  general  paralysis  than  in  mania  or  epileptic  insanity. 
In  the  sane  they  disappear  quickly.  Voisin  (p.  162)  believes 
they  result  from  violence  of  some  kind,  and  acquire  their  peculiar 
character  and  persistency  from  the  cachectic  condition  and  altered 
blood  of  the  patient.     (See  "  Hsematoma  Auris,"  chap.  II.) 

{12,)  Mucou»  Hcemorrhages. — ^There  are  no  ulcerations  of  the 
membranes,  but  there  is  considerable  vascularity.  Haemorrhages 
may  occur  from  the  vaginal,  intestinal,  nasal,  and  buccal  mucous 
membranes,  towards  the  termination  of  the  disease  (Voisin, 
oj).  cif.,  pp.  14.3-167). 

Voisin  describes  five  forms  of  general  paralysis  : — 

(1,)  Acute  General  Paralysis  in  Avhich  the  course  is  rapid, 
the  stages  are  confounded,  and  death  occurs  early  as  a  rule.  It 
may  suddenly  attack  an  apparently  healthy  person  \\dthout  any 
warning. 

(2,)  The  Common  form  of  general  paralysis  in  which  the 
mental  state  is  generally  expansive  and  ambitious.  Often  accom- 
panied by  epileptiform  and  apoplectiform  attacks. 

(3,)  The  form  in  which  symptoms  of  dementia  predominate 
(Paralytic  Dementia).  It  is  the  chronic  form  fxtr  excellence,  and 
is  accompanied  by  few  somatic  troubles. 

(4,)  The  Senile  form  connected  with  atheroma  of  the 
arteries.  In  its  course  it  is  next  in  rapidity  to  Form  1.  It  is 
very  rare. 

(5,)  The  Spinal  form  in  which  the  medullary  troubles 
dominate  the  scene,  and  the  intellectual  are  of  secondary  import- 
ance.    It  is  very  irregular  in  its  manifestations. 

Another  division  of  General  Paralysis  is  into  four  forms,  three 
of  which  depend  on  the  character  of  the  mental  symptoms,  and 
the  fourth  on  their  absence  or  insignificance  :  (1,)  The  expansive 
form ;  (2,)  The  depressive  or  melancholy  form  ;  (3,)  The  demented 
form;  (4,)  The  somatic  form. 

GESTATIONAL    INSANITY. 

Synonym. — Insanity  of  Pregnancy. 

Generally  melancholic  in  character  but  may  be  maniacal. 
3Iild  form. — Mental  depression  or  mental  apathy  not  amounting 
to  stupor ;  loss  of  interest  in  matters  formerly  interesting ;  loss 
of  conscious  affection  for  husband  and  sometimes  for  children ; 
a  slight  weariness  of  life ;  a  fear  of  something  going  to  happen ; 
timidity;    disinclination  for  social  intercourse  (Clouston,  p.  518). 


WITH   THEIR    SYNONYMS   AND   SYMPTOMS.  81 

Severe  form. — In  this  thei-e  may  be  delusions  of  suspicion  as  to 
poison ;  dislike  of  the  husband  ;  dipsomania  ;  kleptomania ;  menda- 
city ;  obscene  language  ;  suicidal  tendency  ;  occasionally  homicidal 
impulse. 

HYPOCHONDRIASIS. 

(See  Melancholia,  Sub-Division  Hypochondriacal  Melancholia.) 

HYSTERICAL     INSANITY. 

Synonyms. — Folie  Hysterique,  Hysterisches  Irresein,  Pazzia 
Isterica. 

Mental  state  of  hysterical  ■pciiients  not  insane. — In  childhood  these 
patients  are  remarkably  intelligent  and  imaginative,  learn  readily 
and  imitate  cleverly  ;  they  are  exceedingly  impressionable,  very 
coquettish,  unblushingiy  mendacious,  and  extremely  eager  to 
attract  attention.  They  suffer  from  migraine,  headache,  insomnia, 
nightmare,  hallucinations,  night  terrors,  and  sometimes  from  gas- 
tralgia,  ovarian  hipercesthesia,  and  palpitation. 

In  adults  in  whom  hysteria  has  actually  developed,  the  character 
is  infantile  and  extremely  mobile,  the  patients  passing  rapidly 
from  laughter  to  tears,  from  anger  to  amiability,  from  loquacity  to 
mutism,  displaying  what  Huchard  calls  ataxic  morale. 

They  are  very  prone  to  denounce  others,  and  are  much  given  to 
opposing,  contradicting,  and  arguing. 

They  have  a  great  desire  to  be  talked  about  and  consequently 
simulate  various  strange  and  unusual  symptoms,  injuries,  and 
diseases. 

They  manifest  sometimes  a  sort  of  cerebral  laziness  with 
quietude  and  moral  anaesthesia. 

A  few  are  actually  sensual,  more  are  erotic  but  stop  short 
of  actual  sensual  gratification,  others  seem  to  be  averse  to  sexual 
intercourse  but  indulge  in  solitary  vice,  whilst  many  evince  no 
sexual  excitement  whatever. 

Hysterical  delirium  may  break  out  before,  during,  or  after  the 
hysterical  convulsive  attack  or  may  replace  it  (hysterie  larvee). 
This  delirium  is  characterised  by  exaltation,  mobility  of  ideas, 
perversion  of  sentiments,  illusions,  hallucinations  (the  colour  red 
generally  predominating),  automatism,  abulia,  irresistible  im- 
pulses, simulation,  maniacal  agitation  or  stupor,  mutism,  some- 
times a  strong  erotic  tendency,  and  nearly  always  retention  of 
consciousness,  the  patient  remembering  everything  she  has  said 
or  done.  The  exaggeration  and  prolongation  of  this  condition 
constitutes  acute  hysterical  insanity. 

(1,)  Acnte  Hysterical  Insanity. — In  a  hysterical  person,  in  conse- 
quence of  some  emotion,  of  some  menstrual  trouble,  of  weakness 

6 


82  INDEX   OF   MENTAL   DISEASES, 

after  an  illness,  often  after  some  incomplete  hysterical  attack,  there 
is  extreme  agitation  which  develops  into  a  veritable  attack  of  acute 
mania.  This  often  appears  to  replace  the  convulsive  attack 
which  is  completely  absent.  In  most  cases  the  intellectual 
faculties  are  little  affected,  and  the  patients  remember  what  they 
have  done  during  the  attack.  A  passive  acute  form  of  a  depres- 
sive character  has  also  been  observed. 

(2,)  Chronic  Hysterical  Insanity. — May  be  either  maniacal  or 
melancholic.  It  may  be  a  sequela  of  the  acute  form,  or  it  may  arise 
through  progressive  aggravation  of  the  peculiar  hysterical  charac- 
ter. The  patients  become  more  sombre  or  very  violent  and 
passionate  ;  then  they  emaciate,  become  anaemic,  and  even  fall  into 
marasmus.  They  are  constipated,  dyspeptic,  and  suffer  from 
dysmenorrhoea  and  irregular  menstruation.  Finally  chronic 
vesania  is  not  slow  to  appear. 

There  is  sometimes  classical  chronic  mania  with  all  its  symptoms, 
or  profound  melancholia  may  develop  Avith  refusal  of  food,  and 
even  suicidal  tendency,  or,  again,  but  more  rarely,  there  is  a 
form  of  simple  mania  with  egotistical  ideas.  With  many  patients 
there  is  an  erotic  or  slightly  religious  tinge  in  the  mental 
derangement,  but  by  no  means  with  all. 

In  chronic  hysterical  insanity  there  are  often  exacerbations  at 
the  menstrual  periods ;  these  are  frequently  accompanied  by 
migraine,  swelling  of  the  upj)er  lip,  and  intestinal  troubles  (Bra, 
"Maladies  Mentales,"  pp.  88-89). 

Savage  ("Insanity,"  p.  87)  says,  "Hysteria  usually  occurs  in 
women,  but  I  have  seen  grave  hysteria  in  young  men ;  and 
although  I  have  never  met  with  true  hemianaesthesia  and  para- 
plegia in  hysterical  young  men,  yet  I  have  seen  some  cases  of 
globus  hj^stericus,  so  that  the  man  passed  from  the  condition  of 
the  hysterical  girl  into  that  of  the  hypochondriacal  man."  He 
also  observes,  "Hysteria  may  colour  other  mental  affections,  that 
is,  an  exaggeration  of  any  one  of  the  perversions  seen  in  hysteria 
may  become  a  delusion." 

Spitzka  ("Insanity,"  p. 257)  writes,  "Hallucinations  are  frequent 
in  chronic  hysterical  insanity,  and  usually  of  the  kind  described 
by  Wundt  as  fantastic  hallucinations  of  hypochondriacs,  being  the 
outcome  of  the  patient's  fancy  and  fears." 

Griesinger  ("Die  Pathologic  und  Therapie  der  Psychischen 
Krankheiten,"  4te  Anflage,  s.  185)  states  that  the  melancholic  or 
maniacal  forms  of  the  chronic  insanity  of  hysterical  patients  are 
developed  from  easily  noticed  though  at  first  moderate  changes  of 
character  ;  sadness  of  disposition,  a  degree  of  egotism  not  formerly 
evinced,  valetudinarianism,  great  indecision  and  abulia,  im- 
patience, violence,  and  irascibility. 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  83 

IDIOCY. 

(Including  Congenital  Imbecility,  and  Cretinism.) 

Esquirol  defines  idiocy  as  "A  condition  in  which  the  intellectual 
faculties  are  never  manifested ;  or  have  never  been  developed 
sufficiently  to  enable  the  idiot  to  acquire  such  an  amount  of 
knowledge  as  persons  of  his  own  age,  and  placed  in  similar  cir- 
cumstances with  himself,  are  capable  of  receiving.  Idiocy  com- 
mences with  life,  or  at  that  age  which  precedes  the  development 
of  the  intellectual  and  affective  faculties,  which  are,  from  the  first, 
what  they  are  doomed  to  be  during  the  whole  period  of 
existence  "  (Bucknill  and  Tuke,  "Psychological  Medicine,"  p.  150). 

"  The  degraded  condition  of  the  idiot  is  very  clearly  displayed 
in  his  vacant  stare,  in  the  thick  everted  lips,  the  slavering  mouth, 
the  irregular,  crowded,  and  decayed  teeth ;  the  gums  often 
swollen,  the  frequent  strabismus,  the  ill-formed,  generally  large 
ears,  and  the  absence  or  defect  of  one  or  more  of  the  senses — 
sight,  hearing,  speech,  taste,  or  smell.  His  staggering  walk  is 
also  very  striking ;  yet  he  seems  as  if  he  must  be  in  motion  if  he 
is  on  his  feet ;  and  even  if  seated  has  a  difficulty  in  balancing 
himself.  There  is  a  general  want  of  symmetry ;  the  limbs  are 
frequently  contracted  or  paralysed ;  the  fingers  are  long  and 
slender  ;  the  grasp  of  the  hand  feeble  or  powerless,  while  the 
extremities  are  often  cold  and  bluish  from  imperfect  circulation. 
Psychologically,  we  may  regard  the  idiot  with  M.  Seguin,  as 
badly  served  by  imperfect  organs,  the  instincts  limited,  but  im- 
perious, sensation  and  reflex  action  taking  the  place  of  attention, 
comparison,  judgment,  memory,  foresight,  and  will"  (Bucknill 
and  Tuke,  op.  cit.,  p.  151). 

Esquirol  speaks  of  three  degrees  of  idiocy,  viz.  :  (1,)  That  in 
which  isolated  words  and  short  phrases  are  used;  (2,)  That  in 
which  only  monosyllables  or  certain  cries  are  used  ;  (3,)  That  in 
which  speech  is  absent. 

Bucknill  and  Tuke  (oj).  cit.,  p.  152)  speak  of  three  classes  of 
idiots,  viz.  :  (1,)  Those  who  exhibit  nothing  beyond  the  reflex 
movements  known  as  the  excito-motor  ;  (2,)  Those  whose  reflex 
acts  are  consensual  or  sensori-motor,  including  those  of  an  ideo- 
motor  and  emotional  character  ;  (3,)  Those  Avho  manifest  volition, 
whose  ideas  produce  some  intellectual  operation,  and  consequent 
will. 

Dr.  Down  classifies  idiots  ethnologically ;  Caucasians,  Ethio- 
pians, Malays,  Mongolians,  being  all  found  typified  among 
them. 

Dr.  Ireland's  classification  of  idiocy  is  :  (1,)  Genetous  or  congeni- 
tal idiocy  ;  (2,)  Microcephalic  idiocy  ;  (3,)  Eclampsic  idiocy  ;  (4,) 


84  INDEX   OF   MENTAL   DISEASES, 

Epileptic  idiocy;  (5,)  Hydrocephalic  idiocy;  (6,)  Paralytic 
idiocy;  (7,)  Cretinism — see  post;  (8,)  Traumatic  idiocy;  (9,) 
Inflammatory  idiocy  ;  (10,)  Idiocy  by  deprivation,  i.e.,  the  loss  of 
two  or  more  senses  (Bucknill  and  Tuke,  oji.  at.,  p.  157). 

I. — Genetous  or  Congenital  Idiocy. 
Characters  :  Often  dwarfish ;  deformities  common,  especially  a 
highly  vaulted  palate  ;  teeth  irregularly  placed  and  subject  to 
decay  ;  deficient  growth  of  finger  nails,  clubbed  fingers ;  squint- 
ing and  rolling  of  the  eyes;  cyanosis,  deficient  cardiac  valves, 
lobulated  form  of  kidneys. 

II. — Microcephalic  Idiocy. 
The  circumference  of  the  head  may  be  as  small  as   14-|  inches. 
These  patients  are  quick  and  quarrelsome  ;  they  "improve  under 
training,  and  have  more  physical  and  moral  energy  than  is  com- 
mon with  idiots  of  other  classes." 

III. — Eclajsipsic  Idiocy. 
Suceeds   infantile  convulsions  chiefly  during  dentition.     The 
child,  although  motion  and  sensation  (general  and  special)  are  un- 
injured, is  capable  of  very  little  education. 

IV. — Epileptic  Idiocy. 

"If  during  the  intervals  between  their  epileptic  seizures,  they 
learn  anything,  a  new  attack  is  apt  to  erase  it  from  their 
memory ;  they  are  generally  "vWld  and  intractable,  and,  indeed 
seem  to  be  on  the  boundary  between  imbecility  and  insanity" 
(Quotation  from  Dr.  Ireland  in  Bucknill  and  Tuke's  "Manual," 
p.  159). 

V. — Hydrocephalic  Idiocy. 

In  twelve  cases  the  head  did  not  exceed  24  inches  in  cir- 
cumference. Dulness  of  touch  and  deafness  not  uncommon. 
Albers,  of  Bonn,  says  that  mental  obtuseness  and  paralysis 
indicate  eflfusion  in  the  lateral  ventricles,  and  restlessness  and 
mental  derangement  in  the  sac  of  the  arachnoid. 

VI. — Paralytic  Idiocy. 
Paralysis  may  take  the  form  either  of  paraplegia  or  of  hemi- 
plegia.     Mentally   these   patients   are   generally   tracttible   and 
.  docile. 

VII. — Cretinism  (See  below). 

VIII. — Traumatic  Idiocy. 
Due  to  injuries  by  attempts  at  abortion,  and  by  the  use  of  the 
forceps.     The  mental  impairment  may  be  trifling  or  severe,  per- 
manent or  temporary. 


WITH   THEIR   SYNONYMS    AND   SYMPTOMS.  85 

IX. — Inflammatory  Idiocy. 
Cases  following  so-called  attacks  of  brain  fever.      In  one  case 
described  by  Dr.  Ireland,  the   patient  possessed  all  his  senses 
and  normal  sensibility,  and  was  learning  to  read  and  write. 

X. — Idiocy  by  Deprivation. 

Idiocy  owing  to  the  absence  of  two  or  more  of  the  principal 
senses. 

IMBECILITY. 
Synonym. — Congenital  Imbecility. 

A  minor  degree  of  mental  deficiency  than  idiocy.  Imbeciles 
think,  feel,  and  speak,  and  are  capable  of  acquiring  a  certain 
amount  of  education.  Some  imbeciles  are  affectionate  ;  many 
are  passionate  ;  many  have  a  strong  tendency  to  theft ;  some  are 
shrewd  and  jocular ;  not  a  few  are  dangerous,  prone  to  homicide, 
and  incendiarism ;  occasional  ones  devote  their  lives  to  works  of 
benevolence. 

Hoft'bauer's  Three  Classes  : — 

I. — Imbeciles  incapable  of  forming  a  judgment  on  a  new  sub- 
ject, but  capable  of  judging  regarding  subjects  familiar  to  them. 
The  memory  is  very  weak,  although  a  certain  routine  of  occupa- 
tion is  observed  -with  scrupulous  exactness  ;  they  do  not  talk 
much  to  themselves  ;  they  are  liable  to  sudden  paroxysms  of  anger. 

II. — Those  who  are  even  less  able  to  judge  and  act,  in  regard 
to  their  accustomed  occupations  ;  they  are  exceedingly  confused 
in  regard  to  the  place  in  which  they  are  and  the  person  with 
whom  they  converse,  and  are  very  generally  at  fault  in  regard  to 
their  ideas  of  time. 

III. — Those  who  have  delusions  of  the  evil  intentions  of  others, 
and  are  not  only  passionate,  but  suspicious  and  misanthropic  ; 
they  frequently  talk  to  themselves  (Bucknill  and  Tuke,  op.  cit., 
pp.  162-163). 

CRETINISM. 

"An  arrested  development  of  the  nervous  system  and  bodily 
organization  generally,  either  before  or  after  birth,  due  to  a  local 
cause,  as  the  condition  of  the  soil,  water,  air,  etc.,  and  marked  by 
characters  which  in  some  respects  distinguish  it  from  ordinary 
idiocy  "(Bucknill  and  Tuke,  op.  cit.,  p.  164). 

"A  certain  combination  of  symptoms  may  allow  us  to  prognos- 
ticate, in  childhood,  the  future  development  of  cretinism.  In 
well  marked  cases  it  is  stated  that  after  the  fifth  or  sixth  month 
the  child  presents  the  foUoAving  symptoms  :  The  development  of 
the  body  proceeds  very  slov/ly  ;  the  child,  though  weak,  is  re- 
markably stout,  and  appears  swollen  ;  the  colour  of  the  skin  is 
sometimes  dusky,  sometimes  yellow,  sometimes  natural ;  the  head 


86  INDEX   OF   MENTAL   DISEASES, 

is  large  ;  the  fontanelles  widely  separated  and  sometimes  all  the 
sutures  disjointed ;  the  expression  is  stupid,  the  appetite  is 
voracious,  and  much  time  is  passed  in  sleep  ;  the  belly  is  swollen : 
the  extremities  are  generally  attenuated  ;  the  neck  is  thick,  with- 
out, however,  being  alwa.ys  goitrous  ;  teething  is  not  completed 
for  many  years  and  is  accompanied  by  an  offensive  salivation,  and 
frequently  by  convulsions.  Usually  the  child  cannot  stand 
before  its  sixth  or  seventh  year,  and  it  is  then  that  it  begins  to 
articulate  certain  sounds,  if  not  deaf  from  birth ;  the  voice 
is  hoarse  and  shrill,  and  words  are  spoken  with  difficulty.  The 
development  of  cretinism,  strictly  speaking,  occui's  about  seven, 
but  it  is  clear  that  all  its  main  features  were  present  long  before" 
(Bucknill  and  Tuke,  ojy.  cit.,  p.  167). 

Some  cases  are  really  congenital.  Dr.  Guggenbiihl's  classifi- 
cation is:  (1,)  Congenital  cases  ;  (2,)  Kachitic  cases  ;  (3,)  General 
atrophic  cases ;  (4,)  Hydrocephalic  cases. 

The  classes  generally  spoken  of  by  authors  are:  (1,)  Cretins, 
manifesting  only  vegetative  functions  and  deprived  entirely  of  re- 
productive and  intellectual  faculties,  including  the  power  of 
speech;  (2,)  Semi-cretins,  possessing  the  power  of  reproduction, 
and  some  faculty  of  speech ;  intellectual  faculties  limited  to 
corporeal  wants;  (3,)  Cretinous,  having  intellectual  faculties 
superior  to  the  former,  and  able  in  some  degree  to  apply  to  trade 
and  other  employments  (Bucknill  and  Tuke,  oj).  cit.  p.  168). 

The  crania  of  the  second  and  third  class  (megalocephales)  are 
more  capacious  than  those  of  the  first.  Some  cretins  are 
brachyocephalic,  and  in  some  the  head  is  conical.  Face  almost 
unchanged  from  puberty  to  old  age,  eyes  expressionless,  generally 
strabismus,  very  large  zygomatic  arch,  mouth  remarkably  lai'ge, 
lips  thick,  the  lower  one  hanging  down  ;  superior  maxilla  promi- 
nent, the  inferior  small,  retreating,  and  obtuse-angled.  Deafness  is 
very  frequent. 

Feet  disproportionately  large,  abdomen  prominent,  resting  upon 
lank,  attenuated  legs,  head  sometimes  cumbrously  large,  drooping 
over  an  ill-developed  thorax.  The  thyroid  gland  may  be  en- 
larged or  there  may  be  supra-clavicular  fatty  swellings  without 
any  bronchocele. 

Many  cretins  are  only  3  feet  high ;  they  are  mostly  under  4 
feet,  and  rarely  exceed  4  feet  11  inches,  though  they  may  attain 
even  6  feet  (Bucknill  and  Tuke,  op.  cit.  pp.  168—170). 

IMPULSIVE     INSANITY. 

Synonyms. — Inhibitory  Insanity,  Psych  okinesia  or  Hyper  kinesis 

of  Clouston  ;  Emotional  or  Affective  Insanity  (Maudsley) ; 

Paranoia  Rudimentaria  Impulsiva  (Morselli). 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  87 

The  loss  of  the  poAver  of  inhibition  is  the  chief  and  by  far  the 
most  marked  symptom.  Action  in  cases  of  morbid  impulse  may 
take  place  from  a  loss  of  controlling  power  in  the  higher  regions 
of  the  brain,  or  from  an  over-development  of  energy  in  certain 
portions  of  the  brain,  Avhich  the  normal  power  of  inhibition  can- 
not control.  In  the  former  division  consciousness  may  be  aljsent, 
the  ego,  the  will,  being  non-existent  for  the  time.  Murders 
committed  during  somnambulism,  hypnotism,  or  epileptic  un- 
consciousness are  the  most  perfect  examples.  In  other  cases 
consciousness  is  present  but  power  of  self-restraint  absent ;  as 
when  imbeciles  and  dements  appropriate  articles  (Clouston, 
"Mental  Diseases,"  1st  ed.,  p.  317). 

These  states  of  morbid  impulse  may  be  momentary  or  constant, 
slight  or  most  intense. 

Morbid  impulses  may  present  themselves  in  several  forms 
of  mental  disease,  e.g.,  the  destructive  impulse  in  mania ;  pyro- 
maniacal  impulse  in  pubescent  insanity,  epileptic  insanity  and 
iml^ecility ;  the  homicidal  impulse  in  epileptic  insanity,  climacteric 
insanity,  melancholia;  the  suicidal  impulse  in  alcoholic  insanity, 
puerperal  and  gestational  insanity;  the  wandering  impulse  (mania 
errabunda)  in  early  general  paralysis,  and  in  j)ubescent  and 
periodical  insanity ;  planomania  in  simple  mania  and  moral 
insanity. 

In  Impulsive  Insanity,  properly  so  called,  a  morbid  impulse  con- 
stitutes the  most  prominent  or  even  the  only  perceptible  symptom, 
and  there  is  neither  delusion,  exaltation,  depression  nor  enfeeble- 
ment ;  dipsomania  and  kleptomania  are  examples. 

The  principal  varieties  of  morbid  impulse  are  :  (1,)  Destructive 
mania,  the  impulse  to  destroy  ;  (2,)  Dipsomania,  the  impulse  to 
drink  intoxicating  liquors.  The  dipsomaniacal  fits  (which  are 
periodical)  are  ushered  in  by  sadness,  moroseness,  headache, 
prascordial  anxiety  and  dyspepsia,  then  the  desire  to  drink  be- 
comes irresistible,  and  the  patient  never  stops  drinking  until  the 
attack  ceases  or  the  patient  is  isolated  (Bra,  "  Maladies  Mentales," 
p.  69,  quoting  Marce).  After  several  days  of  excess  alcoholic 
delirium  appears  with  painful  hallucinations,  tremor,  insomnia, 
gastric  troubles,  amnesia,  etc.,  (Bra,  op.  dt.  p.  70).  The 
dipsomaniac  only  indulges  Avhen  the  impulse  to  drink  seizes 
him ;  the  drunkard  drinks  whenever  he  has  the  opportunity. 
When  the  dipsomaniacal  imjDulse  is  frequently  yielded  to,  chronic 
alcoholic  insanity  is  induced  ;  (3,)  Homicidal  mania,  the  impulse 
to  kill;  (4,)  Kleptomania,  the  impulse  to  steal;  (5,)  Lycanthro- 
pia,  the  impulse  to  act  like  a  wild  beast ;  (6,)  Necrophilism,  the 
impulse  to  exhume  and  eat  dead  bodies  (Clouston,  op.  cit.  p.  317). 
Spitzka  ("Insanity,"  p.  43)  defines  necrophilism  as  a  name  given 


88  INDEX   OF   MENTAL   DISEASES, 

to  a  desire  to  violate  dead  bodies  and  would  classify  it  as  a 
propensity,  not  as  an  impulse  ;  (7,)  Nymphomania,  uncontrollable 
sexual  impulse  in  the  female.  Should  be  distinguished  from 
erotomania  in  which  there  are  delusions  but  not  necessarily 
animal  sexual  desire;  (8,)  Planomania,  the  impulse  to  wander 
from  home  and  throw  off  the  restraints  of  society  (Clouston, 
op.  at.  p.  317) ;  (9,)  Pyromania,  the  impulse  to  set  things  on  fire. 
Is  usually  exhibited  at  or  shortly  after  puberty  (Spitzka);  (10,) 
Satyriasis,  uncontrollable  sexual  impulse  in  the  male;  (11,) 
Suicidal  mania,  the  impulse  without  any  depression  to  commit 
suicide.  Several  of  the  above  morbid  impulses  may  be  combined 
in  the  same  patient ;  (12,)  General  psychokinesia,  impulsiveness 
in  all  directions  (Clouston,  p.  319). 

Spitzka  (p.  271)  looks  upon  dipsomania  as  a  form  of  periodical 
insanitf.  He  also  says  (p.  37)  that  "pyromania,  like  klepto- 
mania, may  be  a  leading  manifestation  of  periodical  insanity." 

Maudsley  considers  impulsive  insanity  and  moral  insanity  to  be 
two  sub-divisions  of  emotional  or  affective  insanity.  (See  "  Moral 
Insanity.") 

KATATONIC    INSANITY. 

Synonyms. — Katatonia  (Kahlbaum),  Pazzia  Catatonica  (Morselli). 

Spitzka  (p.  149)  defines  katatonia  as  "a  form  of  insanity 
characterised  by  a  pathetical  emotional  state  and  verbigeration, 
combined  with  a  condition  of  motor  tension."  He  says  the  initial 
stage  resembles  that  of  ordinary  melancholia.  Then  there  is 
a  period  of  almost  cyclical  alternation  of  atony,  a  peculiar  excite- 
ment, confusion,  and  depression  merging  into  a  state  of  mental 
weakness  approaching,  if  not  reaching,  the  degree  of  a  terminal 
dementia.  Any  one  of  these  phases  may  be  absent.  In  many 
cases  the  initial  stage  is  accompanied  by  cramps,  chorea-like 
movements  of  the  facial  muscles  and  epileptiform  and  hysterical 
convulsions. 

In  some  cases  the  initial  depression  is  accompanied  by  self- 
reproaches  relating  to  masturbatory  excesses,  and  very  frequently 
disappointment  in  love  determines  the  morbid  ideas  of  the 
patient.  On  this  basis  fear  of  poisoning,  delusions  of  persecution 
and  dread  of  committing  unpardonable  crimes  crop  up. 

The  excited  stage  presents,  as  it  were,  a  connecting  link  be- 
tween agitated  melancholia  and  delusional  insanity.  Some  of  the 
patients  present  exaggerated,  others  diminished,  self-esteem.  The 
delirium  not  rarely  assumes  an  expansive  tinge.  All  katatoniacs 
exhibit  a  peculiar  pathos,  either  in  the  direction  of  declamatory 
gestures  and  theatrical  behaviour,  or  of  an  ecstatic  religious  exal- 
tation.     "  Frequently  the  patients  wander  about  imitating  great 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  89 

actors  or  preachers,  and  often  express  a  desire  and  take  steps  to 
become  such  preachers  and  actors."  In  addition  to  the  manufac- 
turing of  words  and  sounds  resembling  words  or  verbigeration 
(see  "  Verbigeration,"  Chap.  II.  of  this  work),  there  is  a  tendency, 
noted  by  Kahlbaum,  to  use  diminutive  expressions.  The  halluci- 
nations are  commonly  of  a  depressive  character,  the  Devil,  hell 
fire,  blood,  "  droves  of  dogs,"  etc.,  etc.  Yet  there  is  rarely  the 
profound  painful  emotional  state  of  true  melancholia.  The  facial 
exjiression  often  indicates  rather  a  silly  hilarious  tendency  even  in 
the  atonic  states,  and  this  reaches  its  acme  in  the  excited  phases. 
The  acts  and  ideas  in  the  latter  states  are  exceedingly  monotonous, 
and  the  tendencies  are  oppositional  and  destructive  ;  hence  refusal 
of  food  and  refusal  to  leave  his  bed,  distinguishing  the  katatoniac 
from  the  maniac.  "  Occipital  headache  of  an  occasionally  severe 
character  is  said  to  be  characteristic  of  katatonia  by  Kahlbaum." 
The  most  striking  phenomena  of  the  disorder  are  its  cataleptic 
periods.  The  catalepsy  is  typical  and  extreme.  It  may  last  for 
days,  weeks,  or  months.  Some  writers  deny  the  existence  of 
katatonia  as  a  pathological  entity. 

LACTATIONAL     INSANITY. 

Synonym. — Insanity  of  Lactation.     Included  by  some  authors 
in  Puerperal  Insanity. 

Generally  melancholic  in  character  but  occasionally  maniacal, 
and  still  less  frequently  assuming  the  form  of  dementia. 

Early  Symptoms. — Pallor,  emaciation,  headaches,  uneasy  sen- 
sations at  the  top  of  the  head,  shortness  of  breath,  palpitation, 
sense  of  weakness  and  sinking,  giddiness,  flashes  of  light  before 
the  eyes,  lassitude,  nervous  irritability. 

Developed  Stage. — Depression,  sleeplessness,  loss  of  self- 
control,  lethargy  and  stujoidity,  or  suicidal  tendency  with 
delusions  of  suspicion,  apprehensiveness,  ideas  of  unworthiness, 
delusions  as  to  personal  identity,  hatred  of  relatives,  hullucina- 
tions  of  sight,  smell  and  hearing  {Clouston,  p.  510;  Savage, 
p.  380 ;  Bucknill  and  Tuke,  p.  364). 

MANIA. 
Synonyms. — Psychlampsia  (Clouston) ;  Tobsucht,  Manie. 
Defined  by  Clouston  ("Mental  Diseases,"  1st  ed.,  p.  143)  as 
mental  exaltation  or  delirium,  usually  accompanied  by  insane 
delusions,  always  by  a  complete  change  in  the  habits  and  modes  of 
life  mental  and  bodily,  by  a  loss  of  the  power  of  self-control,  some- 
times by  unconsciousness,  and  loss  of  memory  of  past  events,  and 
almost  always  by  outward  muscular  excitement,  all  those  symp- 


90  INDEX   OF   MENTAL   DISEASES, 

toms  showing  a  diseased  acti^dty  of  the  brain  convolutions.  In 
this  definition  Clouston  includes  acute  delirium  (acute  delirious 
mania,  delirium  grave). 

Mania  may  be  divided  into:  (1,)  Simple  mania;  (2,)  Acute 
mania  ;  (3,)  Delusional  mania  ;  (4,)  Chronic  mania  ;  (5,)  Transi- 
tory or  ephemeral  mania. 

SIMPLE  MANIA. 

Synonyms — Mania    sine   delirio    (Griesingcr)  ;    Maniacal 
Exaltation  (Krafft-Ebing) ;  Hypomania  (Mendel). 

Loquacity,  especially  about  the  patient's  own  private  affairs, 
the  patient  not  having  been  previously  markedly  loquacious  ;  im- 
paired judgment ;  increased  egotism ;  fickleness,  restlessness, 
unsettled  conduct,  foolish  manner  ;  motiveless  action ;  diminution 
of  power  of  self-control.  These  symptoms  being  not  merely 
transitory,  but  lasting  for  days  or  weeks. 

Griesinger  {op.  at.  p.  302)  says,  "The  frequent  states  of  incom- 
pletely developed  mania  are  of  great  practical  importance." 

Clouston  (yOp.  cit.,Y>.  146)  states  that  the  greater  number  of  cases 
of  so  called  "Moral  Insanity"  are  cases  of  simple  mania.  In  the 
severe  forms  of  simple  mania  there  may  be  insomnia  or  muscular 
or  sexual  excitement.  There  may  be  extreme  mendacity,  absurd 
boastfulness,  disgusting  obscenity.  Clouston  {op.  cit.,  p.  160)  is 
of  opinion  that  the  primare  verrilcktheit  of  the  Germans  may  at 
first  usually  be  classed  as  simple  mania ;  also  that  the  folie 
raisonnante  of  the  French  corresponds  in  a  general  way  to  the 
milder  cases  of  simple  mania.  But,  although  the  symptoms 
resemble  each  other,  primHre  verruclctheit  and  folie  raisonnante  are 
degenerative  states,  and  should  not,  strictly  speaking,  be  con- 
founded with  simple  mania,  which  is  a  psychoneiu'osis,  (Krafft- 
Ebing,  Spitzka). 

According  to  Clouston  {op.  dt.,  p.  160),  simple  mania  is  very 
often  the  first  stage  of  acute  mania. 

ACUTE  MANIA. 

(1.)  It  may  commence  as  simple  mania;  (2,)  It  ma}''  begin 
quite  suddenly  ;  (3,)  It  is  often  preceded  by  a  melancholic  stage 
(4,)  It  sometimes  begins  by  a  delusion  out  of  which  the  extrava- 
gancies arise;  (5,)  Sometimes  it  begins  by  emotional  exaltations 
and  perversions  ;  (6,)  Sometimes  by  intellectual  exaltations  and 
perversions;  (7,)  Sometimes  by  both;  (8,)  It  may  begin  by 
alterations  of  habit,  appetite,  and  propensity  (Clouston,  op.  cit., 
p.  163). 


with  their  synonyms  and  symptoms.  9! 

Premonitory  Symptoms. 
It  commonly  has  premonitoiy  symptoms  bodily  and  mental, 
isuch  as  headaches,  a  confused  feeling  in  the  head,  muscular 
fidgetiness,  unrest  of  body  and  mind,  a  feeling  that  something  is 
going  wrong,  or  that  something  dreadful  is  to  happen,  a  sensation 
as  if  the  head  were  about  to  burst ;  an  impulsive  desire  to  do 
:something,  to  break  glass,  to  be  violent  to  those  within  reach  ; 
usually  disturbed  sleep,  with  unpleasant  dreams  ;  the  temperature 
may  rise  to  100°  before  the  patient  becomes  maniacal  (Clouston, 
loc.  cit.). 

Developed  Stage. 

Great  restlessness  and  muscular  agitation ;  complete  change  of 
■emotional  state,  this  often  becoming  very  joyous ;  rapid  and  un- 
controlled passing  of  the  ideas  through  the  mind  ;  vivid  kaleido- 
scopic mental  pictures  of  the  past ;  scraps  of  former  life  and 
experience  suggested  by  chance  associations  ;  tendency  to  talk 
constantly  whether  any  one  is  present  or  not,  passing  from  one 
thing  to  another  and  soon  becoming  incoherent ;  manner  quite 
•changed,  jolly  or  fierce  ;  sometimes  ceaseless  laughing,  or  scolding, 
■or  swearing ;  sometimes  auditory  and  visual  hallucinations,  and 
■consequent  conversations  in  loud  tones  ;  sometimes  hallucinations 
■or  illusions  of  smell  and  touch  •  the  senses  may  be  hyper  aesthetic 
at  first,  but  afterwards  become  dulled ;  there  may  be  rhythmical 
movements  :  frequently  a  tendency  to  shut  the  eyes  to  exclude 
■external  impressions ;  there  is  perversion  or  paralysis  of  the 
affective  sensibility ;  those  previously  most  liked  are  nov/  most 
disliked ;  those  most  tiusted  previously  are  now  the  objects  of 
suspicion  ;  those  formerly  most  intimate  are  now  shunned  ;  the 
patient  may  shout,  sing,  run  about  wildty,  or  attack  those  near 
him  ;  if  he  writes  at  all  he  writes  very  incoherently  ;  the  face  is 
flushed,  the  eyes  glisten,  the  eyelids  are  widely  dilated,  showing 
the  sclerotic  above  and  below  the  cornea  (Clouston,  oj).  cit., 
pp.  163-170). 

In  acute  mania  there  may  be  delusions.  These  may  be  fixed  or 
fleeting,  and  may  assume  various  forms,  suspicious,  ambitious, 
etc. ;  the  patient  may  fancy  himself  galvanized,  poisoned,  etc.  ; 
or  he  may  believe  himself  to  be  a  king,  an  emperor,  etc.  Illu- 
sions as  to  personal  identity  are  common. 

When  the  acute  symptoms  pass  off  there  may  be  prostration, 
depression,  stupor,  or  apparent  mental  enfeeblement  resembling- 
dementia.  Certain  mental  peculiarities  remain  permanently  in 
many  cases  (Clouston,  ojj.  cit.,  p.  179). 

In  a  case  of  acute  mania  under  the  care  of  the  writer,  there 
was  first  a  short  febrile  attack  without  mental  symptoms ;  then 


92  INDEX   OF   MENTAL   DISEASES, 

insomnia  and  severe  headache,  vertigo,  relieved  by  the  sitting 
posture  and  the  application  of  ice ;  then  hyperacousia  with 
delusions  of  suspicion ;  then  exaltation  with  improvement  of 
memory,  great  loquacity,  and  a  tendency  to  write  very  long 
letters  ;  then  incoherence,  restlessness,  motor  excitement,  and  a 
tendency  to  use  blasphemous  language  and  threaten  violence, 
though  these  threats  were  never  put  into  execution.  The  case 
ended  in  recover):^  after  a  duration  of  about  six  months.  After 
the  fever  of  invasion  subsided,  the  temperature  remained 
normal. 

The  less  severe  forms  of  acute  mania  are  called  suh-amte  mania 
by  some  alienists. 

DELUSIONAL  MANIA. 

Maniacal  general  symptoms  centring  round  a  fixed  delusion  or 
set  of  delusions.  The  delusions  constitute  the  most  prominent 
symptom.  They  are  not  systematised  as  in  delusional  insanity 
(monomania). 

CHRONIC  MANIA 

Synonym. — Chronic  Confusional  Insanity. 

Acute  and  sub-acute  mania  may  pass  into  a  chronic  condition 
of  which  the  most  prominent  characteristics  are  :  restlessness  ; 
want  of  affection ;  want  of  self-control ;  always  weakness  of 
judgment ;  often  weakness  of  memory ;  sometimes  incoherence, 
destructiveness  or  violence,  or  all  three ;  sometimes  delusions 
which  are  fixed  but  not  systematised,  and  hallucinations  of 
various  kinds.  The  patients  may  be  wet  and  dirty.  They 
often  sleep  very  little.  Many  are  able  to  work  and  are  industrious 
in  various  ways.  Chronic  mania  is  often  only  a  stage  on 
the  way  to  terminal  dementia. 

TRANSITORY  OR  EPHEMERAL  MANIA. 

Synonyms. — Transitory  Insanity,  Transitory  Frenzy. 

A  rare  form  of  maniacal  exaltation.  It  conies  on  suddenly,  is- 
usually  sharp  in  its  character,  and  accompanied  by  incoherence, 
partial  or  complete  unconsciousness  of  familiar  surroundings,  and 
sleeplessness.  It  may  last  from  an  hour  up  to  a  few  days 
(Clouston,  op.  rit,  p.  202). 

MASTURBATIONAL     INSANITY. 

Synonyms. — Masturbatory  Insanity,  Insanity  of  Masturbation. 

"It  comes  on  in  youth ;  it  generally  begins  by  an  exaggerated 
and  morbid  self-feeling,  or  by  a  shallow,  conceited  introspection,. 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  93 

or  by  a  frothy  and  emotional  religious  condition,  or  by  a  restless 
and  unsettled  state,  with  foolish  hatchings  of  philanthropic 
^schemes.  There  is  no  continuity  or  force  in  any  train  of  thought 
or  course  of  action.  Then  comes  a  melancholic  stage  of  solitary 
habits,  disinclination  for  company,  especially  that  of  the  other 
sex ;  irritability,  variableness  of  mood,  hypochondriacal  brooding, 
vacillation,  and  perversion  of  feeling  towards  near  relations ; 
suicide  is  often  thought  of,  and  oftener  talked  of,  but  masturba- 
tion makes  most  of  its  victims  too  cowardly  to  kill  themselves. 
Then  an  acute  attack  follows,  usually  of  a  maniacal  kind.  This  may 
.end  in  recovery  or  may  run  quickly  into  a  dementia  that  is 
masturbational  in  character,  being  solitary,  unsocial  and  subject 
to  impulses,  sometimes  homicidal — a  sort  of  masturbational 
hyperkinesia — all  these  being  incurable.  With  these  mental 
.symptoms  there  are  usually  well  marked  bodily  signs  of  the 
disease.  The  patient  is  thin,  pale,  and  pasty,  with  a  cold, 
.clammy  skin,  a  haggard  face,  and  an  eye  that  never  looks 
.straight  at  you.  He  has  weakness  in  the  back,  pains  in  the  head, 
palpitation  of  the  heart,  impaired  sight,  muscular  relaxation,  and 
;Sometimes  spermatorrhoea"  (Clouston,  "Ment.  Dis.,"  1st  ed.,  pp. 
484-485). 

Spitzka  ("Insanity,"  p.  54)  says  that  false  taste  and  smell 
perceptions  are  almost  characteristic  of  masturbatory  insanity, 
and  that  they  are  of  bad  import  and  indicate  rapid  deterioration. 
The  patients  "smell  dead  bodies,  putrefying  and  filthy  sub- 
istances,  noisome  gases,  seminal  discharges,  etc." 

MELANCHOLIA. 

Synonyms.. — Psychlampsia  (Clouston) ;  Lypemania,  Lypothymia. 

Prodromal    Period. 

The  invasion  is  rarely  sudden.  There  may  be  a  vague  sadness, 
an  indefinable  malaise,  a  dislike  of  work,  puerile  fears  (Bra, 
j)p.  cit.,  p.  23), 

Clouston  (oj).  cit.,  p.  127)  says  that  melancholia  "begins  in  nearly 
all  patients  as  simple  lowness  of  spirits,  and  lack  of  enjoyment  in 
occupation  and  amusement,  and  loss  of  interest  in  life  ;  this  may 
be  premonitory  of  the  disease  by  months  or  even  years."  There 
is  at  first  a  painful  mental  state  which  may  continue  in  the 
-form  of  a  vague  feeling  of  anxiety,  oppression,  dejection,  and 
gloom  ;  generally  this  feeling  passes  into  a  single  painful  percep- 
tion, false  ideas  arise,  the  intellect  becomes  slow  and  sluggish, 
and  the  thoughts  monotonous  and  vacant  (Criesinger,  op.  cit., 
p.  213),. 


94  INDEX   OF   MENTAL   DISEASES, 

Sub-divisions  :  (1,)  Simple  melancholia  ;  (2,)  Hypochondriacal 
melancholia;  (3,)  Delusional  melancholia;  (4,)  Agitated  melan- 
cholia; (5,)  Suicidal  melancholia;  (6,)  Religious  melancholia;. 
(7,)  Stuporous  melancholia ;  (8,)  Chronic  melancholia. 

SIMPLE  MELANCHOLIA  (FULLY  DEVELOPED). 
Physical    Symptoms. 

The  countenance  expresses  inquietude,  distrust,  indifference,, 
self-effacement,  or  inertia.  The  attitude  is  almost  always  immo- 
bile ;  the  eyes  are  fixed  on  the  ground  ;  there  is  an  insiurnountable 
aversion  to  movement  of  any  kind.  The  voice  evinces  want  of 
energy;  it  is  weak  and  indistinct,  and  the  words  are  badly  articu- 
lated. There  is  anorexia ;  there  are  also  sitophobia  and  constipation. 
The  pidse  is  slow  and  small,  and  the  temperature  lowered ;  the 
respirations  are  slow  and  irregular.  The  general  sensibility  and 
the  special  senses  are  enfeebled.  The  secretions  are  diminished  ; 
sexual  appetite  diminished  ;  continuoiis  insomnia  and  obstinate 
cephalalgia  (Bra,  op.  cit.,  pp.  23-25).  The  movements  are  slow, 
languid,  and  feeble. 

Psychical  Symptoms. 

A  state  of  mental  pain;  a  profound  feeling  of  ill-being;  of 
inability  to  do  anything ;  of  depression  and  sadness.  Impressions 
formerly  agreeable,  now  excite  pain  ;  irritability  and  irascibility. 
There  is  either  perj^etual  expression  of  discontent  or  a  resort 
to  complete  solitude ;  dislike,  often  absolute  hatred,  of  family, 
relatives  and  friends.  There  may  be  slowness,  monotony, 
hesitancy  or  even  a  total  absence  of  reaction  of  the  will  to  im- 
pressions. Some  melancholies  are  discoiitented,  others  indifferent, 
others  completely  self-absorbed,  others  again  Avho  call  themselves 
miserable  creatures  and  say  everything  is  too  good  for  them.  The 
mind  is  occupied  by  a  few  ideas  and  onl}'  a  few  monotonous  com- 
plaints are  uttered  ;  desire  for  intellectual  intercourse  diminished. 
Patient  speaks  timidly,  hesitatingly,  in  a  low  tone  with  frequent 
self-interruptions,  or  he  may  sit  perfectly  mute. 

The  melancholic  insane  ideas  have  one  essential  character,  that 
of  passive  suffering,  of  being  controlled  and  overpowered 
(Griesinger,  p.  227,  ef.  seq.). 

HYPOCHONDRIACAL     MELANCHOLIA. 

Synonym. — Hypochondriacal  Insanity. 

Change  of  disposition  without  any  assignable  cause,  dejection, 
peevishness,  suspiciousness,  extreme  sensibility,  and  a  disposition 
on  the  part  of  the  patient  to  connect  e^-erything  with  himself. 
Everything  Avearies  the  patient,  and  he  is  very  easily  fatigued. 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  95 

At  first  there  are  many  remissions,  and  the  paroxysms  assume 
the  form  of  an  irritable,  restless,  and  distrustful  disposition,  or  a 
mental  apathy  which  may  produce  weariness  of  life,  or  anxiety 
which  may  proceed  to  despair  and  loss  of  self-control. 

There  nmy  be  morbid  sensations,  formications,  sensations  of  heat 
and  cold,  of  bursting  of  head,  of  emptiness,  etc.  These  sensations 
are  anxiously  watched  and  their  importance  exaggerated.  The 
hypochondriac  often  feels  his  pulse,  examines  his  tongue  and  his 
excretions.  He  reads  medical  books  and  changes  his  medical 
adviser  frequently.  In  the  higher  gTades  Abolition  is  altogether 
absent.  In  the  more  advanced  stage  everything  that  does  noo  fall 
within  the  circle  of  pre-occupying  ideas  is  ■\Wthout  the  slightest 
interest,  of  perfect  indifference,  and  soon  forgotten. 

These  patients  are  therefore  often  extremely  absent-minded  and 
forgetful.  They  are  very  loquacious  upon  the  one  subject  of 
their  affection,  but  are  little  inclined  to  converse  about  anything 
else.  In  the  most  severe  grades  the  patients  are  dull,  morose, 
and  almost  incapable  of  any  intellectual  exertion  (Griesinger, 
p.  217,  et  seq.). 

The  hypochondriacal  melancholic  or  insane  patient,  as  dis- 
tinguished from  the  mere  hypochondriac  or  sane  patient,  has  real 
and  intense  mental  depression  that  he  cannot  throw  off;  he  loses  his 
self-control,  outrages  decency  openly,  practises  things  that  will 
soon  end  his  days,  or  threatens  to  take  his  own  life,  and  cannot  at 
will  Avithdraw  his  mind  and  speech  from  his  delusion.  There  is, 
however,  no  line  of  demarcation.  Hypochondriasis  is  often  the 
first  stage  of  hypochondriacal  melancholia  (Clouston,  oj).  cit. 
pp.  55-56). 

Savage  {op.  cit.  p.  131)  states  that  there  are  three  classes  of 
cases  of  ordinary  hypochondriasis  seen  in  an  asylum  besides  the 
sufi'erers  from  general  hypochondriasis  who  complain  of  syphilis 
or  hydrophobia  or  believe  themselves  about  to  die.  Savage  here 
evidently  uses  the  term  hypochondriasis  as  synonymous  with 
hypochondriacal  insanity.     These  three  classes  are  : — 

I. — Brain  Hypochondriasis  affecting  both  men  and  women, 
and  in  which  the  patients  l^elieve  the  brain  to  be  dried  up  or 
changed  in  some  way.  This  form  is  liable  to  occur  about  the 
climacteric. 

II.^Gastric  Hypochondriasis  which  he  subdivides  into  (1,) 
Patients  who  complain  of  obstruction  or  disease  about  the  throat  ; 
(2,)  Those  who  complain  of  similar  feelings  and  uneasiness  at 
the  pit  of  the  stomach;  and  (3,)  Those  whose  complaints  are 
referred  to  the  lower  bowel.  These  cases  are  furnished  chiefly 
though  not  solely  by  persons  of  mature  years,  and  more  fre- 
quently by  men  than  women. 


96  INDEX   OF   MENTAL   DISEASES, 

The  Gastro-enteric  Insanity  of  Sibbald  ("Quain's  Dictionary," 
p.  724)  would  seem  to  be  a  sort  of  symiDtomatic  link  between 
Savage's  Gastric  Hypocbondriasis  and  Simple  Melancholia.  Sibbald 
Avrites  :  "  In  addition  to  the  mere  depression  caused  by  anaemia, 
there  is  associated  with  such  affections  a  peculiar  anguish  of  mind 
and  tendency  to  self-accusation,  which  is  often  of  the  most  distress- 
ing nature.  Refusal  of  food  is  often  a  prominent  symptom.  The 
intellectual  perversion  is  slight,  and  seldom  so  prominent  as  in 
other  acute  insanities.  Eelief  of  the  bodily  symptoms  is  generall}' 
accompanied  by  a  return  to  sanity."  The  affections  most  fre- 
quently causing  it  are  irritation  and  catarrh  of  the  mucous 
membrane ;  constipation ;  stricture  or  other  causes  of  distension 
oi  the  viscera ;  and  epigastric  tumours  (See  "  Abdominal 
Disorders,  Insanity  of  ").  Hypochondriasis  is  not  infrequently 
induced  by  real  bodilj^  disorders. 

III. — Sexual  Hypochondriasis.  Middle-aged  men  who  fancy 
themselves  impotent,  and  youths  who,  having  given  way  to 
masturbation,  fancy  they  are  suffering  from  spermatorrhoea, 
^exual  hypochondriasis  is  rarely  met  with  in  Avomen. 

Krafft-Ebing  looks  upon  hypochondriacal  melancholia  as  a 
primary  affection  not  developing  out  of  hypochondriasis,  and  gives 
as  two  of  its  forms  melancholia  syphilophobica  and  melancholia 
hydrophobica.  According  to  him  (p.  592,  et  seq.)  mental  weak- 
ness or  hypochondriacal  paranoia  may  develop  out  of  hypochon- 
.driasis. 

Clouston  {ojj.  cit.,  p.  55)  remarks  :  "  In  hypochondriacal  melan- 
.cholia  a  sense  of  ill-being  is  substituted  for  the  healthy  pleasure 
,of  living,  but  the  ill-being  is  localised  in  some  organ  and  function 
of  the  body.  The  patient's  depressed  feelings  all  centre  round 
himself,  his  health,  or  the  performance  of  his  bodily  or  mental 
functions.  He  is  all  out  of  sorts,  he  cannot  digest  his  food, 
his  bowels  will  neA^  er  act,  his  kidneys  or  liver  are  wrong,  he  has 
no  stomach,  his  heart  is  weak,  and  he  asks  you  to  feel  his  pulse 
which  is  just  going  to  stop  beating.  He  is  paralysed  and  will  not 
move  a  limb  till  he  forgets  his  fancy  for  a  moment ;  he  cannot 
think  because  his  brain  is  made  of  lead  ;  he  is  made  of  glass  and 
will  break  if  roughly  handled.  There  are  no  limits  to  the  fancies 
,of  the  hypochondriac  or  the  hypochondriacal  melancholic." 

In  a  case  under  my  care  the  patient  laboui'ed  under  the  delusion 
that  he  suffered  from  obstruction  of  the  bowels,  and  would  con- 
verse about  nothing  else.  He  might  answer  a  few  questions 
probably  quite  correctly,  but  he  immediately  reverted  to  his 
favourite  topic.  He  was  a  man  rather  past  middle  age,  stout  and 
healthy  looking,  with  somewhat  florid  complexion  and  without 
.any  gloominess  of  facial  expression.      He  took  his  food  well  and 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  97 

went  daily  for  long  walks  with  a  number  of  other  patients ;  but  he 
did  not  occupy  himself  in  any  other  way,  and  would  have  lain  in 
bed  all  day  had  he  been  allowed.  His  bowels  acted  fairly 
regularly,  and  when  the  attendants  affirmed  that  he  had  recently 
had  an  evacuation,  he  either  denied  the  assertion  or  said  it  was 
only  something  that  had  lodged  below  the  obstruction. 

Another  patient  fancied  his  mouth  and  throat  were  full  of  long 
hairs,  and  he  would  give  anyone  the  end  of  a  hair  as  he  imagined, 
and  walk  backwards  many  yards  declaring  he  could  see  the 
hair  coming  out  of  his  mouth  as  he  retreated.  He  both  felt  and 
saw  the  hairs,  and  at  times  his  agitation  was  extreme  with 
Aveeping  and  motor  excitement.  He  refused  food  and  had  to  be 
fed  forcibly.  His  countenance  expressed  great  anxiety  and 
misery,  and  at  first  sight  his  case  closely  resembled  one  of 
agitated  or  anxious  melancholia. 

DELUSIONAL    MELANCHOLIA. 

This  includes  the  group  of  cases  of  melancholia  in  which  delusions 
(or  a  delusion)  are  the  most  prominent  mental  symj^tom  (Clouston, 
op.  ciL,  p.  63).  The  delusions  are  very  various,  such  as  "  having 
committed  the  unpardonable  sin,"  "  being  extremely  poor," 
"  being  very  wicked,"  "  being  poisoned  ;"  "  that  wife,  or  husband 
and  children  are  being  burnt  alive  or  otherwise  killed,"  "  that  he 
or  she  (the  patient)  has  committed  murders  or  unnatural  crimes," 
"  that  death  is  impending,"  "  that  it  is  sinful  to  take  food," 
"  that  the  patient  is  unworthy  to  eat,"  "  that  every  morsel  taken 
brings  the  patient  and  all  about  him  or  her  so  much  nearer 
ultimate  starvation,"  "  that  it  is  in  fact  wasteful  and  extravagant 
to  take  food." 

AGITATED     MELANCHOLIA. 

Synonyms. — Active  Melancholia  (Savage) ;  Melancolie  Anxieuse 

(Bra) ;  Melancholia  Agitans  (Griesinger) ;  Excited  (Motor) 
Melancholia  (Clouston). 

There  is  a  confused  tumult  of  thought  exj^ressed  by  physical 
restlessness.  The  thoughts  and  movements  are  monotonous  and 
of  little  variety.  The  state  differs  from  mania  through  the 
paucity  of  ideas  and  want  of  fertility.  Sometimes  the  patient 
keeps  up  a  perpetual  motion,  breaks  out  into  frequent  fits  of 
weeping,  and  constantly  wrings  his  hands  (Griesinger,  op.  cit., 
pp.  234-235). 

There  is  extreme  agitation,  and  an  imperious  desire  for  move- 
ment (Bra,  op.  cit.  p.  26). 

"  It  is  characterised  by  restless  misery  as  seen  in  the  constant 
picking  of  fingers,  pulling  out  of  hair,  and  a  tendency  to  strike  or 

7 


98  INDEX   OF   MENTAL   DISEASES, 

damage  anything  that  appears  to  be  an  obstacle  to  its  free 
exhibition.  Generally  in  these  cases  there  is  some  marked 
delusion,  and  most  commonly  this  delusion  is  connected  with  the 
idea  that  someone  else  is  going  to  be  injured  on  her  account " 
(Savage,  op.  cif.,  pp.  175-176). 

SUICIDAL    MELANCHOLIA. 

In  which  the  suicidal  tendency  is  marked  and  prominent. 
Clouston  {op.  cif.,  p.  112)  believes  that  tendency  to  suicide  exists 
in  some  form  or  other,  in  wish,  intention,  or  act,  in  four  out 
of  five  melancholies,  and  we  can  never  tell  Avhen  it  is  to  develop 
in  any  patient. 

Savage  {op.  cit.,  p.  190)  observes  that  the  most  suicidal  patients 
are  those  who  believe  they  are  to  be  injured,  and  that  suicidal 
tendencies  are  most  marked  in  the  early  morning.  He  also  states 
that  heredity  plays  an  important  part  in  the  causation  of  the 
suicidal  tendency. 

The  suicidal  melancholic  (as  distinguished  from  the  subject  of 
impulsive  insanity)  arrives  at  the  determination  to  commit  suicide : 
(1,)  From  a  calmly  and  carefully  reasoned  out  plan  because  he  is 
not  going  to  recover,  or  because  his  death  "will  benefit  his  children, 
or  from  other  similar  motives  ;  (2,)  From  the  desire  to  escape 
imaginary  torture  or  persecution;  (3,)  In  consequence  of  some 
depressive  delusion  or  delusions,  or  of  auditcry  hallucinations 
("  Voices  "). 

Clouston  {op.  cit.,  p.  118)  states  that  in  his  experience  the 
gi'eatest  danger  of  suicide  is  near  the  commencement  of  the 
attack  of  melancholia.  In  some  cases  of  suicidal  melancholia 
there  exists  also  a  homicidal  teiidency. 

EELIGIOUS  MELANCHOLIA. 

Melancholia  Religiosa  (Griesinger). 

Intense  despondency  as  to  religious  condition.  Delusions  as  to 
eternal  damnation,  as  to  having  led  "s^dcked  lives  and  neglected 
the  services  of  religion,  and  caused  others  to  do  so.  Self-accusa- 
tions of  hypocrisy  and  impiirity.  Tendency  to  suicide.  In  a 
case  of  "Religious  Delusional  Melancholia,"  described  by 
Clouston  {op.  cit.,  p.  82),  the  first  symptoms  were  "mental 
confusion  and  depression,  and  falling  oft"  in  bodily  looks,  appetite 
and  strength,  and  her  head  feeling  queer."  On  admission, 
there  were  mental  depression,  impairment  of  memory,  dulling  of 
sensory  functions,  impairment  of  reflex  functions,  and  various 
delusions  of  a  religious  kind  (that  she  was  the  greatest  sinner 
alive,  and  had  committed  many  and  unpardonable  sins). 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS,  99 


STUPOROUS  MELANCHOLIA. 

Synonyms. — Melancholia     with     Stupor    (Savage,    Griesinger) ; 

Melancholic  Stupor  (Clous ton) ;    Melancolie  avec  stupeur  (forme 

active)  of  the  French  authors ;  Melancholia  attonita. 

The  patient  remains  in  one  position  and  attitude,  with  little  or 
no  voluntary  movement.  He  resists  being  moved,  and  compresses 
his  lips  firmly  when  food  is  placed  against  them.  The  features 
are  contracted,  and  the  countenance  expressive  of  wretchedness 
and  misery  or  terror.  The  complexion  is  sallow  or  yellow.  The 
cutaneous  sensibility  is  diminished.  The  pupils  are  generally 
dilated  and  immobile.  Food  is  refused  and  nutrition  fails.  The 
excretions  are  deficient.  Insomnia,  suicidal  tendency,  mutism, 
which  is  generally  absolute  for  the  time  being.  Consciousness 
is  wholly  or  partially  retained,  and  the  patient  as  a  rule  remembers 
and  can  describe  the  frightful  delusions  and  terrifying  hallucina- 
tions frequently  present  in  this  condition.  These  hallucinations 
often  cause  sudden  fits  of  agitation  and  give  rise  to  dangerous 
impulses. 

Stuporous  melancholia  is  often  developed  rapidly.  It  may  be 
primary,  or  succeed  other  forms  of  melancholia,  or  constitute  an 
interlude  in  their  course. 

Any  of  the  foregoing  forms  of  melancholia  may  be  acute  with 
regard  to  the  severity  of  the  symptoms,  or  chronic  in  duration. 

Savage  (oj;.  cit.,  p.  203)  speaks  of  Eecurriitg  Melancholia,  and 
says  cases  of  it  differ  only  in  degree  from  those  in  which  there 
are  several  distinct  attacks  of  melancholia,  each  followed  by  com- 
plete recovery. 

MENTAL  DETERIORATION   (PRIMARY). 

Synonym. — Simple  Primary  Dementia. 

Symptoms. 

Prodromal. — Lack  of  energy,  both  physical  and  mental. 
Insomnia,  or  unrefreshing  dreamy  sleep,  the  dreams  relating 
to  the  patient's  daily  occupations  and  cares.  Dyspepsia. 
Signs  of  functional  or  organic  heart  disorder,  or  of  the  prodromal 
period  of  Bright's  Disease  may  be  noted.  Often  premature  gTay- 
ness  (Spitzka,  "Insanity,"  p.  164). 

Fully  developed. — Absent-mindedness,  failure  of  memory,  lack 
■of  attention,  general  inertia,  impaired  ability  of  acquiring  new 
impressions.  Syllables  and  words  are  omitted  in  writing  ;  impor- 
tant engagements  are  broken,  articles  of  value  mislaid,  expenditures 
unrecorded,  and  with  the  intensification  of  all  these  symptoms 
(Complete  fatuity  may  be  developed. 


100  INDEX   OF   MENTAL   DISEASES, 

With  the  above  symptoms,  the  muscular  power  is  enfeebled, 
the  articulation  is  alfected,  the  pupils  are  unequal,  and  the  tem- 
perature is  subnormal,  while  the  patient  generally  complains  of 
a  sensation  of  pressure  and  fulness  in  the  head  (Spitzka,  "Insanity," 
pp.  164-165). 

Savage's  Partial  Dementia  would  seem  to  be  included  in  this 
form  of  mental  disorder. 

METASTATIC  INSANITY. 

Clouston  (p.  599)  says  the  typical  rheumatic  insanity  is 
essentially  a  metastatic  insanity.  He  speaks  of  cases  where  the 
healing  of  an  old  ulcer  was  followed  by  an  attack  of  insanity ;  of 
erysipelas  of  the  face  "  striking  inwards  "  and  causing  an  attack 
of  acute  mania  ;  of  the  disappearance  of  syphilitic  psoriasis  being 
followed  by  melancholia,  and  its  reappearance  by  mental  recovery. 

MORAL  INSANITY. 

Synonyms. — Manie  sans  Delire  ;  Folie  raisonnante  ;  Monomanie 

affective  ;  Gemiithswahnsinn  ;  Moralisches  Irresein 

(Krafft-Ebing). 

It  "  is  manifested  by  insane  actions  and  conduct,  rather  than  by 
insane  ideas,  delusions,  or  hallucinations."  Dr.  Maudsley  gives 
moral  insanity  and  impulsive  insanity  as  two  sub-divisions  of 
"  emotional  or  affective  insanity "  (Blandford,  "  Quain's  Diet.," 
p.  727). 

Blandford  describes  two  forms,  acquired  and  congenital : — 
(1,)  Acquired  Moral  Insanity. — "A  disorder  of  mind  shown  by  an 
entire  change  of  character  and  habits,  by  extraordinary  acts  and 
conduct,  extravagance  or  parsimony,  false  assertions,  and  false 
views  concerning  those  nearest  and  dearest,  but  without  absolute 
delusion.  Such  a  change  may  be  noticed  after  any  of  the  ordinary 
causes  of  .insanity.  It  may  folloAV  epileptic  or  apoplectic  seizures, 
or  may  be  seen  after  a  period  of  drinking.  Its  a^Dproach  is 
gradual,  as  a  rule,  rather  than  sudden,  and  the  extraordinary 
character  of  the  acts  may  not  at  first  be  so  marked  as  subse- 
quently  Such  insanity,   of  course,   varies  in  degree. 

When  it  is  well  marked,  and  the  conduct  is  outrageous,  there 
will  be  no  difficulty  in  the  diagnosis.  But  it  may  be  less  marked  ; 
it  may  consist  of  false  and  malevolent  assertions  concerning 
people,  even  the  nearest,  of  little  plots  and  traps  to  annoy 
others,  in  which  great  ingenuity  and  cunning  may  be  displayed. 
And  there  will  be  the  greatest  plausibility  in  the  story  by  which 
all  such  acts  and  all  other  acts  mil  be  explained  away  and 
excused."  Blandford  says  further,  "It  may  be  necessary  to 
prevent  a  man  from  squandering  all  his  property — a  common 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  101 

symptom  in  this  variety — or  from  wandering  from  home  and 
absenting  himself  no  one  knows  where,  or  keeping  low  company.'"' 
(2,)  Congenital  Moral  Insanity  (Moral  Imbecility) ;  Moralische 
Idiotie;  Originarer  Moralischer  Schwach — und  Blodsinn  (KrafFt. 
Ebing). — "The  congenital  moral  defect  occasionally  met  Avith 
in  persons  who  have  been  from  birth  odd  and  peculiar, 
and  incapable  of  acting  and  beha\ang  like  other  people.  They 
can  hardly  be  called  idiots  or  imbeciles,  for  they  may 
exhibit  a  considerable  amount  of  intellect  and  even  genius 
in  certain  special  directions.  We  shall  generally  find  that 
they  are  the  offspring  of  parents  strongly  tainted  with 
insanity,  epilepsy  or  alcoholism,  and  many  in  childhood  are  the 
subjects  of  fits,  chorea,  or  other  neurosis.  They  are  incapable  of 
being  instructed  like  other  boys  -and  girls ;  are  often  frightfully 
cruel  towards  animals,  or  their  brothers  and  sisters,  and  seem 
utterly  incapable  of  telling  the  truth  or  understanding  why  they 

should  do  so These  are  the  persons  who  commit  crimes, 

and  become  the  chronic  inmates  of  prisons  ;  and  it  is  most  difficult 
for  medical  and  other  prison  officials  to  say  how  far  they  are 
responsible  and  how  far  not "  (Blandford.  he.  cit.). 

MYXffiDEMA  (Insanity  of). 
Savage  ("Insanity,"  p.  418)  remarks  that  a  sense  of  sus^^icion 
and  of  in]iu"y  is  common  in  these  cases.  In  the  cases  he  quotes  the 
principal  symptoms  are  delusions  of  suspicion  and  persecution ; 
hallucinations,  sometimes  of  sight,  sometimes  of  hearing;  violence 
and  threatening  in  one  case,  restlessness,  sleeplessness,  and  much 
depression  in  another:  feebleness  of  memory,  dulness  of  per- 
ception. Then  there  are  the  physical  signs — Cretinoid  physiog- 
nomy, slow  and  muffied  speech,  impaired  sight  and  hearing, 
hard  and  dry  skin,  subnormal  temperature.  Atrophy  of  thyroid. 
The  tendency  is  to  pass  slowly  but  steadily  into  dementia. 

NEURASTHENIA    AND    NEURASTHENIC     INSANITY. 

NEURASTHENIA. 
(Beard,  Arndt,  Krafft- Ebing.) 
Severe  or  Constitutional  Form. 
As  a  rule  it  is  developed  gradually,  the  early  symptoms  being 
relieved  by  rest  and  sleep.     There  are  at  first  phenomena  of 
exhaustion ;  lassitude ;   weakness  ;    dislike  of  mental  work  and 
difficulty  in  performing  it ;  craving  for  sleep,  nourishment,  drink, 
and  even  the  means  of  excitement  and  enjoyment.       The  patient 
is  overwhelmed   by   the  fear  of  impending  illness  of  a  serious 
nature.     Symptoms  of  irritation  are  soon  added  ;  there  is  irrita- 
bility,   and  Avhat  sleep  the  patient   obtains   is   light,    dreamy, 


102  INDEX   OF  MENTAL   DISEASES, 

interrupted,  unrefreshing.  Vaso-motor  symptoms  also  occur 
early;  local  hypersemia  (rush  of  blood  to  the  head,  palpitation, 
feeling  of  oppression,  etc.),  and  local  anemia  (vascular  spasm 
amounting  to  local  asphyxia,  feeling  of  cold,  etc.).  The  most  im- 
portant symptom,  however,  is  the  feeling  of  broken  strength, 
bodily  and  mental,  with  the  resulting  depression  and  fear  of 
impending  illness,  a  fear  amounting  finally  to  inconsolable 
nosophobia.  Neurasthenia  may  be  cerebral,  spinal,  visceral,  or 
sexual.     For  Causes,  see  Chap.  TV. 

Cerebral  Neurasthenia. — There  may  be  mental  incapacity, 
psychical  angesthesia,  mental  blindness  and  deafness,  and 
even  amnesic  aphasia  and  agraphia.  The  never-failing  mental 
depression  is,  unlike  melancholia,  reactive  ;  nevertheless  there  are 
fleeting  transitions  to  that  disease.  Imperative  conceptions 
(fixed  ideas)  are  frequent,  and  are  sometimes  accompanied  by 
suicidal  or  misanthropic  tendencies.  A  feeling  of  pressure  on  the 
head  is  hardly  ever  absent,  and  it  is  accompanied  by  nosophobic 
ideas  of  cerebral  ramollissement  and  threatened  insanity. 
Asthenopia  is  frequent  and  cystospasm  is  not  rare. 

Spinal  Neurasthenia. — In  this  form  the  patients  rapidly  be- 
coming feeble  feel  depressed,  complain  of  paralgise  in  skin, 
muscles,  and  joints,  are  exhausted  after  very  slight  exertion, 
suffer  from  palpitation,  sudden  sweating,  and  feelings  of  oppres- 
sion and  anxiety  ;  sleep  is  disturbed  by  startings.  There  may  be 
paraesthesise  and  even  local  anaesthesia.  Spinal  irritation  is 
especially  frequent,  and  gives  rise  to  an  exceedingly  obstinate 
idea  that  the  spinal  cord  is  diseased. 

Amongst  the  Visceral  Neurasthenice,  Neurasthenia  Cordis  is  the 
most  prominent.  In  this  form  there  are  attacks  of  cardiac 
disturbance  and  intervallary  symptom-s.  During  the  attacks 
there  is  a  feeling  of  arrest  of  the  heart's  action ;  there  are  pain, 
pressure,  and  vibrations  in  the  cardiac  region.  Fear  of  apoplectic 
attacks  aggravates  the  patient's  condition.  Diu-ing  the  intervals 
the  patient  is  languid,  exhausted,  emotional,  nosophobic.  In 
Neurasthenia  Gastrica  there  are  dyspeptic  troubles  with  pressure 
on,  and  rushes  of  blood  to,  the  head ;  there  are  somnolence, 
palpitation,  etc.,  etc. 

Sexual  Neurasthenia. — There  are  nocturnal  emissions,  and  on 
attempting  coitus  ejaculation  is  premature.  There  is  fear  of 
disease  of  the  spinal  cord.  These  depressing  influences  induce 
psychical  impotence.  There  are  paralgiae  and  neuralgiae  in  the 
region  of  the  lumbo-sacral  jdIcxus.  Spinal  neurasthenia  becomes 
developed,  and  even  general  neurasthenia  may  supervene,  acci- 
dental circumstances  determining  which  form  (cerebral,  gastric, 
etc.)  is  at  any  given  time  predominant.     The  sexual  neurasthenic 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  103 

is  shy,  oppressed-looking,  self-depreciative  with  hypochondriacal 
depression,  ataxiaphobia,  indolent  attitude,  lowered  muscular 
tone,  pale  complexion  with  Avell-nourished  body,  tremor  to  helpless- 
ness and  motor  ataxy  when  he  knows  he  is  being  observed.  There 
are  also  dyspepsia,  flatulence,  constipation,  gxeat  alteration  in  the 
frequency  of  the  pulse  under  the  influence  of  emotion  or  bodily 
exertion  (it  will  sometimes  run  up  to  120  under  these  influences), 
fits  of  general  vascular  spasm  with  violent  palpitation  and 
paroxysmal  anguish  and  oppression  in  the  cardiac  region.  To 
these  symptoms  must  be  added  the  peripheral  genital  and  the 
lumbar  cord  neuroses  with  aggravation  of  the  psychical  troubles 
by  repeated  ejaculations.  In  women  the  general  phenomena  are 
the  same  as  in  men. 

THE  NEURASTHENIC  PSYCHOSES. 
There  are  two  groups,  psychoneurotic  and  degenerative.  The 
psychoneurotic  group  is  composed  of  cases  developing  on  a  basis 
of  neurasthenia  which  is  acquired,  episodical,  or  at  all  events  not 
constitutional.  The  psychoses  of  this  gTOup  may  be  transitory  or 
protracted.  The  protracted  cases  take  the  form  of  melancholia, 
stapor,  and  acute  confusional  insanity. 

NEURASTHENIC    PSYCHONEUROSES. 

I. — Transitonj  Neurasthenic  Insanity  apjoears  sometimes  as  the 
culminating  point  of  neurasthenia  cerebralis,  and  is  accompanied 
by  external  signs  of  inanition  and  exhaustion,  such  as  tremor  and 
subnormal  temperature.  There  are  sensory  disturbances  ex- 
tending to  loss  of  perception,  blurring  of  consciousness  amounting 
in  some  cases  to  unconsciousness  with  corresponding  defects  of 
memory,  loss  of  speech  and  movement,  anxiety.  Isolated 
delirious  ideas  appear  in  this  almost  or  quite  stuporous  condition, 
and  give  rise  to  dreamy,  odd  actions.  The  pupils  are  wide  and 
sluggish.     The  pulse  is  small  and  wiry. 

II. — Protracted  Neurasthenic  Psychonewoses.  Most  cases  of 
anergic  stupor  (acute  dementia)  and  acute  confusional  insanity 
(Wahnsinn ,  belong,  according  to  Krafft-Ebing,  to  this  category. 
Maniacal  symptoms  rarely  develop  on  a  neurasthenic  basis, 
melancholic  ones  very  frequently.  Masturbatory  melancholia  is 
one  of  these  forms  of  melancholia  characterised  more  by  restrained 
mental  action  than  by  psychical  pain.  Melancholia  masturbatoria 
develops  on  a  basis  of  sexual  neurasthenia.  Nosophobic  symptoms 
(fear  of  insanity,  tabes,  or  incurable  impotence)  are  never  absent 
during  the  stage  of  incubation.  In  the  developed  disease  there  is 
great  self-depreciation.  The  seldom  failing  olfactory  hallucinations 
lead  the  patient  to  believe  he  emits  an  evil  odour.      Attempts  at 


104  INDEX   OF  MENTAL   DISEASES, 

suicide  are  common,  so  also  is  mutilation  of  the  genitals.  There 
may  be  attacks  of  angina  pectoris  vaso-motoria,  at  night.  In 
severe  cases  there  are  often  observed  uncleanliness,  disgusting 
habits  (eating  excrement,  rain  worms,  the  contents  of  spittoons, 
etc.),  fixed  ideas,  and  a  religious  delusional  state  (the  Messiah, 
etc). 

NEURASTHENIC   DEGENERATIVE    PSYCHOSES. 

I. — Mental  disorders,  of  which  the  chief  symptoms  are 
Imperative  Conceptions  (fixed  ideas,  idees  fixes,  Zwangsvorstel- 
lungen).  (See  "Folie  du  doute,"  "Partial  Emotional  AbeiTation.") 
Krafft-Ebing  holds  the  "\-iew  that  these  cases  are  developed  on  a 
basis  of  neurasthenia  nearly  always  constitutional  and  hereditary. 
In  the  rare  cases  in  which  the  disease  is  acquired  through  certain 
causes  (see  "  Etiology  ")  recovery  may  take  place  in  time.  This 
psychosis  may  be  accompanied  by  hysteria  or  hypochondriasis, 
and  melancholia  may  occur  episodically. 

II. — Xeurasthenic  Paranoia  is  a  form  of  paranoia  (monomania, 
delusional  insanity)  in  which  the  delusions  are  founded  on  the 
sensations  occurring  in  the  neui'asthenic  neurosis.  The  patient's 
thoughts  are  disturbed  through  the  cunning  machinations  of 
enemies  ;  his  dyspeptic  troubles  are  the  result  of  attempts  to 
poison  him,  etc.  Hallucinations  are  developed  later,  and  these 
are  especially  numerous  when  sexual  neurasthenia  is  the  basis,  as 
in  paranoia  masturhatoria.  In  this  form  there  are  hallucinations  of 
smell  and  hearing,  illusions  of  sight  and  hearing,  physical  perse- 
cutory delusions,  fits  of  apprehension,  etc. 

HI. — Most  cases  of  Melancholic  Folie  liaisonnante  (q.v.)  (KrafFt- 
Ebing,  "Lehrbuch  der  Psychiatrie,"  p.  517,  et  seq.). 

OVARIAN  OR  OLD  MAID'S  INSANITY. 

"The  disease  usuallj^  occurs  in  unprepossessing  old  maids,  often 
of  a  religious  life,  who  have  been  severely  virtuous,  in  thought, 
word  and  deed,  and  on  Avhom  nature  just  before  the  climacteric 
takes  revenge  for  too  severe  a  repression  of  all  the  manifestations 
of  sex,  by  arousing  a  grotesque  and  baseless  passion  for  some 
casual  acquaintance  of  the  other  sex,  whom  the  victim  believes  to 
be  deeply  in  love  with  her,  dying  to  marry  her,  or  aflame  with 
sexual  passion  towards  her,  or  who  has  actually  ravished  her  after 
having  given  her  chloroform.  Usually  her  clergyman  is  the 
subject  of  this  false  belief."  "Such  patients  are  all  of  them 
between  thirty -five  and  forty-three,  and  the  reverse  of  sensuous 
in  appearance"  (Clouston,  "Mental  Diseases,"  p.  478).  Out  of 
ten  of  Clouston's  cases,  seven  have  had  clergymen  as  their  supposed 
wooers  or  seducers. 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  105 


OXALURIA  AND  PHOSPHATURIA  (Insaiiity  of). 

Clouston  (p.  597)  observes,  "All  writers  on  the  urine  have 
noticed  the  hypochondriasis,  depression  of  mind,  want  of  energy 
and  originating  power,  and  the  irritability  that  so  often  go  along 
with  the  presence  of  much  oxalate  of  lime,  or  phosphates  in  the 
urine."  He  says  further  (p.  598),  "I  think  there  is  scarcely 
enough  evidence  to  show  whether  this  condition  of  the  urine  is  a 
cause,  or  an  effect  of  the  brain  state." 

PARALYSIS  AGITANS  (Insanity  ofj. 

When  paralysis  agitans  is  of  long  continuance,  the  facial 
expression  becomes  heavy  and  sad,  the  intellect  blunted,  the 
memory  unreliable,  sleep  difficult  to  obtain  and  disturbed.  The 
patient  is  irritable,  fickle,  and  difficult  to  get  on  with. 

Ordinarily,  the  symptoms  go  no  further,  but  in  some  cases  real 
insanity,  with  illusions  and  hallucinations,  develops,  and  usually 
takes  the  form  of  simple  melancholia,  or  anxious  melancholia. 
Occasionally,  delusions  of  persecution  are  observed.  These 
mental  troubles  are  intimately  associated  with  the  disorders  of 
sensation,  and  increase,  diminish,  or  disappear  with  them.  They 
are  amenable  to  the  same  treatment  (Bra,  "  Manuel  des  Maladies, 
Mentales,"  p.  94). 

PARTIAL  EMOTIONAL  ABERRATION. 

In  this  form  there  is  insane  feeling,  usually  fear  or  apprehension, 
limited  to  certain  positions  or  surroundings.  The  principal 
varieties  are  agoraphobia,  claustrophobia,  and  mysophobia.  Less 
important  forms  are  anthropophobia,  monophobia,  and  astraphobia. 

Agoraphobia. — In  this  variety,  there  is  a  dread  of  being  alone  in  a 
wide  space.  If  the  patient  finds  himself  in  this  position,  he  suffers 
from  intense  dread,  palpitation,  giddiness,  cold  perspiration.  He 
tries  to  seize  any  person  or  object  near  him.  If  taken  into  a 
small  apartment,  he  becomes  cjuite  well. 

Claustrophobia. — The  same  sensations  are  felt  in  a  confined  or 
shut  place. 

Mysophobia. — Morbid  fear  of  defilement,  causing  the  patient  to 
refuse  to  touch  other  persons.  When  touched  by  others,  he  will 
rub  or  wash  the  part  touched  (see  folie  du  doute).  In  some  cases 
the  patients  are  afraid  that  they  themselves  will  defile  others,  but 
this    approaches    melancholia    of    a     hypochondriacal     natiu-e. 

Anthropophobia. — Morbid    dread    of    society. 

Monophobia. — Morbid  dread  of  being  alone. 


106  INDEX   OF   MENTAL   DISEASES, 

Astraphobia. — Morbidly  intense  fear  during  thunderstorms. 
(Robertson,  "Finlayson's  Clinical  Manual,"  pp.  351-352). 

Krafft-Ebing  {op.  cit.  p.  70)  considers  that  in  these  cases  the 
patient  is  seized  by  the  idea  (imperative  conception,  Zwangsvor- 
stellungen,  fixed  idea),  that  he  cannot  cross  the  street,  square,  etc., 
and  thereupon  gets  into  a  nervous  condition  with  extreme  fear. 
These  symptoms  are  the  expression  of  an  irritable  weakness  of 
the  nervous  centres,  and  are  founded  on  a  neurasthenic  basis  con- 
stitutional or  acquired.  (See  "  Neurasthenia,"  etc.).  The  well- 
known  impulses,  also,  to  throw  self  or  others  from  towers,  etc.,  are 
generally  felt  when  the  brain  is  exhausted.  Partial  emotional 
aberration  and  folie  du  doute  are  generally  described  together 
as  "  Mental  Disorder  throuaih  Fixed  Ideas." 


PARTIAL  EXALTATION  OR  AMENOMANIA  (Eush). 

Bucknill  and  Tuke  under  the  above  name,  describe  a  form  of 
insanity  closely  resembling  the  ambitious  form  of  delusional  insanity 
(Ambitious  Monomania),  but  differing  in  that  the  exalted  emotional 
condition  is  primary,  and  the  delusions  of  grandeur  are  secondary, 
arising  from  the  emotional  state.  It  is  the  gay,  partial  insanity 
or  monomania  proper  of  Esquirol ;  the  chseromania  of  other 
French  Avriters. 

Esquirol  says,  "Amongst  monomaniacs,  the  passions  are  gay 
and  expansive,  enjoying  a  sense  of  perfect  health,  of  augmented 
muscular  power,  and  of  a  general  sense  of  well-being.  This  class 
of  patients  seize  upon  the  cheerful  side  of  everything ;  satisfied 
"s^dth  themselves,  they  are  content  with  others.  They  are  happy 
and  joyous,  and  communicative.  They  sing,  laugh  and  dance, 
controlled  by  vanity  and  self-love.  They  delight  in  their  own  vain- 
glorious convictions,  in  their  thoughts  of  grandeur,  power  and 
Avealth.  They  are  active,  petulant,  inexhaustible  in  their  loquacity, 
and  speaking  constantly  of  their  felicity.  They  are  susceptible 
and  irritable  ;  their  impressions  are  vivid,  their  affections  energetic, 
their  determinations  A'iolent ;  disliking  opposition  and  restraint, 
they  easily  become  angry,  and  even  fuiious  "  (Bucknill  and  Tuke, 
p.  236). 

This  form  of  insanity  includes  religious  exaltation  or  excitement, 
without  delusions,  illusions,  or  lesion  of  intelligence. 

There  are  ecstatic  expressions  of  happiness,  pride  and  haughti- 
ness, with  a  violent  deportment ;  or,  selfishness,  want  of  natural 
affection,  variableness  of  spirit,  irregular  mental  habits.  Religious 
revivals  afford  many  examples  of  this  form  of  insanity. 

Sankey  holds  pleasurable  exaltation  to  be  a  mere  symptom,  and 
few  authors  treat  it  as  a  separate  form  of  insanity. 


WITH  THEIR   SYNONYMS   AND   SYIVIPTOMS.  107 


PELLAGROUS  INSANITY. 

This  is  a  form  of  insanity  associated  with  pellagra,  and  not 
met  with  in  Britain.  It  is  characterised  hy  mental  symptoms 
usually  indicative  of  anaemia — great  depression,  frequently  with 
tendency  to  suicide,  passing  on  to  chronic  dementia.  It  is  most 
frequently  met  ^vith  in  Italy"  ("Quain's  Dictionary,"  p.  728). 

Morselli  ("Malattie  Mentali,"  vol.  i.,  p.  437)  gives  four  forms 
of  pellagrous  insanity,  viz.,  supra-acute  pellagra  (pellagrous 
typhus),  pellagrous  melancholia,  pellagrous  dementia,  and  pella- 
grous pseudo-general  paralysis. 

PERIODICAL  INSANITY. 

The  attacks  of  insanity  recur  more  or  less  regularly  with  lucid 
or  sublucid  intervals.  There  is  degenerative  taint  shown  by  :  (1,) 
Bad  family  history  of  the  majority  of  the  patients. ;  (2,)  The 
presence  of  somatic  stigmata ;  (3,)  The  coincidence  of  the 
beginning  of  the  disorder  with  certain  physiological  periods, 
such  as  puberty,  and  climacteric ;  its  exacerbations  often 
following  other  physiological  periods,  such  as  menstruation. 

A  form  occurring  at,  or  near,  the  menstrual  periods  has  been 
called  menstrual  inscuiity. 

The  patients  are  much  influenced  by  barometric,  and  seasonal 
conditions. 

The  periodical  outbreaks  are  more  abrupt  both  in  their  com- 
mencement and  termination  than  in  simple  mania  and  melancholia. 
They  also  reach  their  acme  sooner  and  are  shorter.  There  are 
moral  or  affective  perversions,  and  certain  propensities  and  im- 
pulses not  usually  found  in  the  simple  insanities. 

When  the  disease  is  fully  established,  the  attacks  in  the  same 
patient  are  almost  exactly  similar  to  each  other,  displaying  the 
same  propensities,  impulses,  delusions,  hallucinations,  and  language. 

Divided  into  Periodical  Mania,  and  Periodical  Melancholia  : — 

(1,)  Periodical  Mania  may  begin  abruptly  (us^^al  manner),  or 
may  be  heralded  by  such  symptoms  as  palpitation,  vertigo, 
neuralgia,  or  by  a  short  period  of  depression. 

The  maniacal  explosion  is  marked  by  angry  excitement,  moral 
perversion,  and  cUlire  des  ades  (sexual  excesses,  indecent  assaults 
and  exposures;  thefts,  incendiarism,  wandering  abroad,  etc.). 
Outbreaks  of  angry  excitement  of  a  violent  and  dangerous  charac- 
ter are  frequent.  There  are  illusions,  occasionally  hallucinations, 
rarely  delusions. 

Sometimes  a  single  morbid  propensity,  such  as  sexual  perversion, 
is  the  most  prominent  feature.    Morselli  ("  Manuale  di  Semejotica 


108  INDEX   OF   MENTAL   DISEASES, 

delle  Malattie  Mentali,"  vol  i.,  p.  214)  gives  the  following 
forms  of  sexual  aberration  and  perversion,  viz.,  Masturbation 
(solitary  sexual  vice  in  the  male) ;  Clitorism  (solitary  sexual 
vice  in  the  female) ;  Pederasty  (unnatural  intercourse  of  men 
Avith  boys) ;  Sodomy  (unnatural  intercourse  between  adult  males) ; 
Tribadism  (unnatural  sexual  lelations  between  females)  ; 
Bestiality  (coitus  with  an  animal) ;  Sapphism  (cunnilinguism) ; 
mouth  pollution,  etc.  To  these  he  would  add  the  various 
malthusian  methods  of  so-called  preventive  intercourse,  including 
conjugal  or  biblical  onanism.  Alcoholic  stimulants  are  not  well- 
borne,  and  there  is  a  craving  for  them.  KrafFt-Ebing  includes 
maniacal  folie  raisonnante  in  periodical  mania. 

(2,)  Periodical  Melancholia. — "Periodical  melancholiacs  are 
the  most  persistent,  cunning,  and  successful  of  all  suicidal  lunatics  " 
(Spitzka,  "  Insanity,"  pp.  267-271).  Many  mild  cases  never  reach 
asylums  (Krafft-Ebing). 

In  the  lucid  or  sulj-lucid  intervals  (Avhich  may  last  weeks, 
months  or  years)  of  periodical  insanity,  most  of  the  patients  are 
"nervous,"  hysterical,  or  morbidly  irritable.  As  time  goes  on, 
the  character  becomes  permanently  changed,  the  patients  become 
more  irascible,  their  energies  are  diminished,  their  emotions 
blunted  (Spitzka). 

Krafft-Ebing  and  Spitzka  include  circular  insanity  under  the 
head  of  periodical  insanity. 

PHTHISICAL  INSANITY. 

Clouston,  who  has  specially  studied  this  form  of  insanity,  and 
who,  in  fact,  gave  it  its  name,  states  ("  Clinical  Lectures  on 
Mental  Diseases,"  pp.  461-463)  that  there  may  sometimes  be  an 
acute  stage  at  first,  but  that  this  is  not  common,  and  is  always 
short. 

"  Most  frequently  the  disease  begins  by  a  gradual  alteration  of 
disposition,  conduct,  and  feeling  in  the  direction  of  morbid  sus- 
picion of  those  about  the  patient,  a  morbid  fickleness  of  purpose, 
an  unsociability,  an  irritability  and  an  entire  want  of  buoyancy 
and  proper  enjoyment  of  life.  Along  with  this  there  is  loss  of 
weight,  indigestion,  intolerance  of  fat,  want  of  enjoyment  of  food, 
perversion  of  taste  in  regard  to  food,  and  a  bad  colour  of  the  skin. 
There  may  or  may  not  be  any  chest  symptoms  present  ■  most 
frequently  there  are  not.  Then  comes  the  acutest  part  of  the 
attack,  if  there  is  such  a  stage  in  the  case.  The  patient  gets 
sleepless  and  mildly  melancholic,  or  maniacal,  the  bodily  state 
running  down  all  the  time.  The  organic  enfeeblement  that 
characterises  the  disease  is  often  shown  by  refusal  of  food.  The 
patient  thinks  he  is  being  poisoned,  this  no  doubt  being  the  con- 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  109 

volutional  misinterpretation  of  the  pain  and  uneasiness  of  indiges- 
tion. In  a  way  he  is  often  poisoned,  for  his  food  is  badly  digested 
and  assimilated,  and  the  subjective  symptoms  accompanying  this 
are  not  unlike  some  kinds  of  poisoning.  After  a  little,  the  patient 
becomes  irritable,  sullen,  unsociable,  and  suspicious,  his  state 
varying  from  time  to  time.  The  intellectual  processes  are  not  so 
much  enfeebled,  as  there  is  a  disinclination  to  exercise  them. 
There  are  occasional  unaccountable  little  attacks  of  excitement. 
The  patient  is  disinclined  to  amuse  or  employ  himself ;  he  looks 
on  any  attempt  to  do  so  as  persecution,  and  as  being  prompted  by 
hostile  motives.  There  is  some  depression,  but  no  intense  mental 
pain.  The  patient  associates  with  no  one,  and  the  kindnesses  of 
relatives  merely  call  forth  reproaches.  If  the  patient  lives  long, 
he  becomes  more  silent  and  apparently  demented,  but  he  can 
always  be  roused  out  of  this  for  a  short  time.  Complete  typical 
dementia  does  not  usually  occur.  If  there  is  any  tendency  to 
periodicity  the  remissions  and  aggravations  are  not  regular  or 
complete.  Bodily,  he  cannot  be  fattened ;  he  looks  sallow  and 
haggard,  his  circulation  is  poor,  his  pulse  weak,  and  anything  like 
tone  is  entirely  absent.  There  is  no  muscular  energy,  and  a  strong 
disinclination  to  exertion.  The  appetite  is  poor  and  capricious. 
Colds  are  taken  very  easily.  The  patients  loose  weight,  and  are 
all  round  Avorse  in  cold  weather.  The  temperature  tends  to  be 
low,  until  the  lungs  become  affected,  and  then  there  is  an  insidious 
evening  rise,  which  is  perhaps  the  only  sign  of  the  presence  of  a 
bodily  disease.  In  very  many  of  the  cases — one  half  of  the 
number  according  to  my  experience — the  chest  symptoms  are 
at  first  latent,  even  after  the  lungs  have  become  markedly 
affected.  There  is  no  cough,  or  spit,  or  pain.  I  have  often 
happened  to  notice  that  a  patient  labouring  under  phthisical 
insanity  (and  this  applies  to  cases  of  dementia,  and  many  cases  of 
acute  insanity  too)  was  breathing  a  little  more  quickly  than 
normal,  or  was  looking  more  pinched,  or  was  falling  off  his  food, 
or  his  pulse  was  quicker  and  weaker  than  usual,  or  he  had  a  hectic- 
looking  spot  on  one  cheek,  or  his  skin  felt  hot ;  and  on  examining 
the  chest,  in  consequence  of  some  such  indication,  I  have  found 
extensive  broncho-pneumonia,  or  consolidation,  or  breaking  up  of 
the  lung  tissue.  The  progress  of  the  lung  disease  varies  much  in 
different  cases,  in  some  being  rapid  and  causing  death  in  a  few 
months,  and  in  others  going  on  for  years  if  the  conditions,  food, 
and  hygiene  are  favourable.  I  have  seen  such  cases  in  the  very 
feverish  stage  before  death,  when  the  temperature  rose  over  102'*, 
rouse  up  wonderfully,  and  even  cease  to  manifest  the  morbid 
suspicions  ;  but  such  cases  are  exceptional.  It  would  seem  as  if 
in  these  cases,  the  high  temperature  and  quickened  circulation 


no  INDEX   OF   MENTAL   DISEASES, 

stimulated  the  ansemic,  and  ill-nourished  convolutions  to  increased 
and  almost  normal  mental  activity." 

Sankey  ("Lect.  on  Ment.  Dis.")  asserts  that  phthisical  insanity 
is  only  insanity  occurring  in  a  phthisical  patient. 

PODAGROUS  OR  GOUTY  INSANITY. 

The  section  headed  "  Insanity  and  Gout,"  in  Bucknill  and 
Tuke's  "Psychological  Medicine,"  contains  the  following  paragraphs 
(p.  381):- 

"In  the  'Annales  Medico-Psychologiques,'  1869,  Dr.  Bertheir 
records  twenty-two  cases  in  which  the  two  diseases  (insanity  and 
gout)  were  associated. 

"  One  was  a  case  of  Stupor  ;  one.  Delusional  Insanity  of  a  melan- 
choly character ;  two.  Suicidal  Melancholia ;  three,  Simple 
Dementia ;  four,  in  which  the  features  of  the  malady  were  not 
well  defined ;  five,  Dementia  Paralytica ;  six.  General  Mania. 

"  Of  these,  eight  have  been  observed  by  the  author  himself,  and 
in  six  of  them  hereditary  predisposition  was  ascertained. 

"  In  twelve  cases,  the  insanity  was  consecutive  to  disappearance 
of  gout ;  in  eight  cases  it  alternated  with  it ;  in  two  cases  it 
accompanied  the  gouty  condition.  The  great  majority  occurred 
among  males.     He  draws  the  following  conclusions  : — 

"  (1,)  If  the  gout  has  a  marked  action  on  the  mind  of  its  victims, 
and  a  special  predilection  for  the  nerves,  it  may,  under  the 
influence  of  the  predisposition,  become  the  soui-ce  of  every  kind 
of  neurosis,  and  chiefly  those  affecting  the  sight. 

"(2,)  The  psycho-netiroses  dependent  on  the  gouty  diathesis,  are 
sometimes,  and  more  commonly  metastatic  and  alternating,  and 
sometimes  connected  -with  a  specific  condition  which  disposes  the 
system  to  the  development  of  a  latent  or  larval  vesania. 

"  (3,)  Gouty  insanity,  though  generally  associated  with  fixed 
gout,  will,  Avhen  its  study  has  been  completed,  be  frequently 
recognised  in  union  with  wandering  or  anomalous  gout. 

"  (i,)  Sometimes  the  gouty  symptoms  disappear  and  become  lost 
in  the  insanity,  which  then  passes  into  the  chronic  and  incurable 
state  of  dementia. 

"(5,)  Gouty  insanity  must  henceforth  be  regarded  as  having  an 
established  place  in  science,  and  is  to  be  classed  along  with 
dartrous,  syphilitic,  rheumatismal,  etc. 

"  (6,)  It  shows  a  preference  for  the  form  of  general  mania. 

"  (7,)  The  diagnosis  of  gouty  insanity  is  to  be  drawn  from  the 
heredity,  the  antecedents  of  the  patient,  the  connection  of  the 
insanity  vnth  gout,  and  the  presence  in  the  urine  of  the  character- 
istic chemical  ingredients. 

"  Outside  the  walls  of  asylums,  cases  are  frequently  met  with 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  Ill 

which  are  marked  by  symptoms  of  unfounded  dread,  especially 
on  awakening  from  sleep  early  in  the  morning,  in  which  there  is 
a  gouty  diathesis,  and  suspicion  is  aroused  that  there  is  a  causal 
connection  between  the  bodily  condition,  and  the  mental  anguish. 
This  suspicion  is  confirmed  by  the  marked  success  of  treatment, 
founded  upon  the  supposition." 

POST  CONNUBIAL  INSANITY. 

Depression,  suicidal  tendency,  and  stupidity  (Clouston,  p.  607). 

PUBESCENT  INSANITY. 

Synonyms. — Hebephrenia ;  Insanity  of  Puberty ;  Insanity  of 
Pubescence  ;  Hebephrenic  Katatonia  (Kahlbaum). 

"  The  insanity  of  puberty  in  both  sexes  is  characterised  by 
motor  restlessness.  Such  patients  never  sit  down  by  night  or 
day,  and  never  cease  moving.  There  is  noisy  and  violent 
action,  sometimes  irregular  movements,  or,  in  the  few  melancholic 
forms  and  melancholic  stages  of  the  maniacal  cases,  cataleptic 
rigidity.  The  mental  symptoms  consist  most  frequently  of  a  kind  of 
incoherent  delirium,  rather  than  any  fixed  delusional  state.  In 
boys,  the  beginning  of  an  attack  is  frequently  ushered  in  by  a 
disturbance  in  the  emotional  condition — dislikes  to  parents, 
brothers  or  sisters,  expressed  in  a  violent  open  way  ;  there  is  irra- 
tional dislike  to,  and  avoidance  of,  the  opposite  sex.  The  manner 
of  a  grown-up  man  is  assumed,  and  an  offensive  "  forwardness  "  of  air 
and  demeanour.  This  soon  passes  into  maniacal  delirium,  which, 
however,  is  not  apt  to  last  long.  It  alternates  with  periods  of 
sanity,  and  even  AWth  stages  of  depression  "  (Clouston,  op.  cit.,  pp. 
531-532). 

Spitzka  {op.  cit.,  p.  176)  says  this  psychosis  begins  with  a 
period  of  sadness  without  depth,  and  in  which  the  patient  may 
suddenly  burst  out  in  causeless  laughter,  or  even  make  silly  jokes. 

After  this,  there  are  vague  or  blind  propensities,  fickleness  of 
purpose,  malice  to  surroundings.  Then  the  intellect  gradually 
weakens,  and  the  patient,  who  is  generally  a  confirmed  mastiurba- 
tor,  will  pass  into  a  terminal  dementia,  marked  by  occasional 
furious  outbreaks.  He  (Spitzka)  states  that  everything  about 
these  patients  is  shallow,  and  even  unreal.  He  gives  the  age  of 
its  occurrence  as  the  period  between  the  fifteenth  and  twenty- 
second  years. 

Clouston  means  by  "puberty,"'  the  initial  development  of  the 
function  of  reproduction,  or  its  first  appearance  as  an  energy  of  the 
organism;  and  by  "adolescence,"  the  whole  period  of  twelve 
years  from  the  first  evolution  up  to  the  full  perfection  of  the 
reproductive  energy  {op.  cit.,  p.  535). 


112  INDEX   OF  MENTAL  DISEASES, 

Spitzka's  pubescent  insanity,  therefore,  covers  part  of  the  ground 
included  in  Clouston's  adolescent  insanity,  as  the  symptoms  given 
would  indicate. 

PUERPERAL  INSANITY. 

This  may  assume  the  form  of  mania,  melancholia,  or  dementia 
(Savage,  op.  cit.,  p.  371). 

In  one  half  the  number  of  cases,  the  disease  begins  with  the 
first  week  after  confinement,  and  in  three-fourths  of  them,  within 
the  first  fortnight  (Clouston,  cq).  cit.,  p.  494). 

Dr.  Burrows  found  the  third  and  fourth  day  the  most  obnoxious 
to  the  disease  (Bucknill  and  Tuke,  p.  357). 

I.— PUERPERAL  MANIA. 

Eakly  Symptoms. 

Alteration  of  facial  expression,  dull,  self-absorbed  look. 
Sleeplessness,  irritability,  some  depression.  Alteration,  dimi- 
nution, or  suppression  of  the  lochia,  often,  but  not  always ; 
less  frequently  the  milk  is  diminished,  or  its  secretion  sup- 
pressed (Bucknill  and  Tuke,  loc.  cit.).  Patient  takes  a  dislike 
to  her  husband,  or  child ;  refuses  food,  or  takes  it  reluctantly ; 
complains  of  unpleasant  smells.  There  is  headache,  or  an  uneasy 
sensation  izi  the  head. 

Fully  Developed  Stage. 

"Excitement,  chattering,  incoherent,  blasphemous,  or  amorous 
talk."  "Sleeplessness,  anxiety,  aversion  to  relations,  erotic 
tendencies,  mistakes  of  identity,  with  hallucinations  of  smell  and 
taste,  and  refusal  of  food"  (Savage,  op.  cit.,  p.  373). 

"  She  is  restless  ;  her  eyes  are  brilliant.  She  expresses  foolish 
fancies,  such  as  that  she  is  poisoned,  that  there  is  some  one  under 
the  bed.     She  takes  a  violent  dislike  to  the  doctor,  or  the  nurse, 

or  the  child She  gets  violent,  and  needs  to  be  held  in 

bed.  Impulsively,  and  Avithout  set  intent,  she  attempts  to  commit 
suicide,  or  tries  to  kill  her  baby,  or  to  throw  herself  out  of  the 
window.  She  seems  as  if  she  had  a  supernatural  strength ;  yet 
when  you  feel  her  pulse  it  is  weak  and  thready,  her  face  looks 
haggard,  her  temperature  has  risen  to  100°  or  more,  her  womb 
is  tender  on  pressure  over  the  abdomen,  and  she  will  not  look  at 
food  "  (Clouston,  op.  cit.,  p.  495). 

Bucknill  and  Tuke  (p.  359)  say  the  abdomen  is  in  most  cases 
tolerant  of  pressure,  and  the  pulse  is  accelerated  and  usually 
irritable  in  character.  Patients  are  frequently  wet  and  dirty,  and 
destructive. 


WITH   THEIR    SYNONYMS   AND    SYMPTOMS.  113 

Puerperal  mania  only  differs  from  ordinary  mania  in  the  pre- 
dominance of  certain  symptoms,  such  as  constant  babbling, 
homicidal  impulse,  and  the  obscene  and  erotic  character  of  the 
delirium  (Bra).  The  presence  of  suicidal  impulse,  the  refusal  of 
food,  the  absolute  sleeplessness,  the  perversion  of  natural  affection 
are  also  characteristics  of  puerperal  as  compared  with  ordinary 
mania. 

11.— PUERPERAL     MELANCHOLIA. 

Sleeplessness,  anxiety  and  dread,  are  followed  by  delusions  in 
reference  to  husband  or  children,  and  associated  with  hypochon- 
driacal or  other  similar  symptoms.  Melancholic  symptoms 
generally,  but  not  always,  come  on  later  after  delivery  than 
attacks  of  mania  (Savage,  op.  cit.,  p.  377). 

III.— PUERPERAL    DEMENTIA. 

Savage  (p.  379)  observes,  "In  some  cases  after  delivery,  the 
patient  slowly  becomes  apathetic ;  she  takes  little  or  no  notice  of 
her  child,  and  may  be  slightly  emotional ;  her  indifference 
becomes  more  and  more  marked,  till  it  is  recognised  as  a  mental 
disorder.  She  neglects  her  personal  cleanliness,  and  has  to  be 
tended  like  a  child.  This  condition  may  slowly  pass  off,  or  it  may 
be  but  the  early  symptoms  of  an  incuraljle  state  of  dementia.''' 

Clouston  quotes  several  cases  of  puerperal  insanity,  in  which  the 
pulse  attained  120  or  considerably  more,  and  the  respirations 
were  56  or  60.  Of  sixty  cases,  the  temperature  was  under  99° 
in  thirty -four ;  betAveen  99°  and  100°  in  twelve;  over  100°  in 
fourteen,  and  in  five  of  these  over  103°  (pi).  cit.,  p.  506). 

Sankey  denies  the  existence  of  puerperal  insanity  as  a  morbid 
entity. 

REASONING  INSANITY    (FOLIE  RAISONNANTE). 

Griesinger,  Avriting  of  melancholia  with  persistent  excitement 
of  the  will,  mentions  {op.  cit.  p.  275)  that  some  of  the  cases 
of  this  nature  are  adduced  by  authors  as  examples  of  emotional 
insanity,  mania  sine  delirio,  folic  raisonnante,  or  Prichard's  moral 
insanity.  He  further  speaks  of  maniacal  folie  raisonnante  as 
a  state  of  incompletely  developed  mania  which  may  either  end  in 
recovery  or  pass  into  gay  weak-mindedness  or  foolishness 
(moria),  if  the  exaltation,  as  yet  moderate,  does  not  increase  and 
explode  outwardly  as  mania,  or  increase  less  demonstratively 
with  the  development  of  fixed  delusions  until  it  becomes  delu- 
sional insanity. 

Clouston,  as  already  stated^  considers  that  folie  raisonnante 
corresponds  in  a  general  way  to  the  milder  cases  of  simple  mania. 

8 


114  INDEX   OF   MENTAL   DISEASES, 

Krafft-Ebing,  whose  most  recent  classification  (see  end  of  Chap.  I.) 
is  one  of  the  best  lately  proposed,  uses  folic  raisonnante  as  a  terni 
synonymous  "with  "  Constitutional  Affective  Insanity,"  a  de- 
generative functional  psychosis.  He  also,  in  treating  of 
disturbances  of  the  will,  says  that  the  frequent  occurrence  of  cases 
in  which  the  patients  talk  sensibly,  and  are  able  to  excuse  their 
extremely  foolish  actions  with  wit  and  shrewdness,  has  given  rise 
to  the  erection  of  a  special  form  of  insanity,  the  so-called  folie 
raisonnante.  He  subdivides  it  into  maniacal  and  melancholic  folie 
raisonnante.  Cases  of  the  former  display  well-marked  periodicity, 
and  are  in  reality  cases  of  periodical  mania  [delire  des  actes, 
perversions,  etc.).  (See  "  Periodical  Insanity,"  maniacal  form. ) 
Melancholfi  Folie  Eaisonnante. — It  occurs  most  frequently  in 
females.  (For  causes,  see  Chap.  IV.)  There  is  a  constant  ill- 
humour,  a  permanent  depressive  condition  which  expresses  itself 
in  irritability,  discontentedness,  quarrelsomeness,  abusiveness, 
proneness  to  illtreat  surrounding  persons.  Such  patients  are 
abulic,  spiritless,  joyless,  incapable  of  sustained  bodily  or  mental 
Avork,  unhappy,  desponding  to  the  extent  of  tsedium  vitee.  There 
are  remissions  and  exacerbations,  and  the  symptoms  are  more 
strongly  pronounced  at  the  menstrual  periods.  This  disease  is  thus 
distinguished  from  a  mere  evil  disposition.  There  may  be,  though 
there  rarely  are,  fits  of  apprehension  and  delusions  of  persecution. 
Neuropathic  symptoms  (neurasthenia,  spinal  irritation,  hysteria) 
may  complicate  the  paroxysms  of  apparent  ill-humour  and 
irritability. 

RHEUMATIC  INSANITY. 

This  may  be  divided  into  cerebral  rheumatism,  and  rheumatic 
insanity  properly  so-called. 

Cerebral  Rheumatism  in  the  great  majority  of  cases  appears 
during  the  course  of  the  rheumatic  affection,  from  the  fifth 
to  the  twentieth  day.  Its  frequency  is  not  in  constant 
relation  with  the  intensity  of  the  rheumatism ;  ordinarily,  how- 
ever, it  accompanies  the  grave  forms  of  acute  articular  rheumatism. 
It  sometimes  commences  suddenly,  the  articular  pains  diminishing 
a  short  time  before  the  attack.  At  other  times  it  is  announced  by 
matutinal  elevation  of  temperature,  profuse  sweats,  slight  mental 
aberration,  most  frequently  of  the  melancholic  type,  frontal  ceph- 
alalgia, change  of  character,  alteration  of  facial  expression. 
Hallucinations,  vertigo,  embarrassment  of  speech  resembling  that 
of  general  paralysis,  dysphagia,  and  choreiform  movements  often 
open  the  scene. 

The  Severe  or  Supra-acute  form  is  characterised  by  the  rapidity 
of  its  course,  and  suddenly  fatal  termination.     Death  is  sometimes 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  115 

preceded  hy  asphyxia,  coma  (comatose,  depressive,  or  apoplectic 
form),  sometimes  by  violent  delirium  or  convulsions  (meningitic 
form). 

The  Amte  or  less  Severe  form  is  preceded  by  a  prodromal  period 
of  variable  duration  from  a  few  hours  to  a  few  days,  and  manifests 
itself  by  great  loquacity,  extraordinary  exaltation,  alternating  ■with 
moments  of  depression  and  melancholy.  There  are  visual  halluci- 
nations, and,  more  rarely  auditory,  olfactory,  or  gustatory,  dolence, 
suicidal  attempts,  trenwr,  convulsions,,  dyspiwea,  and  sometimes 
.analgesia. 

The  temijerature  in  the  rectum  reaches  109°  F.,  111°  F.,  or  even 
112^  F. 

The  Pidse  is  sriudl  and  frequerd.  This  state  lasts  from  a  few 
hours  to  a  few  days,  and  frequently  terminates  in  coma  and  death. 

Sometimes  the  delirium  appears  in  irregular  attacks,  coming  on 
most  frequently  at  night ;  the  prognosis  is  then  more  favourable 
(Bra,  ojx  cit.,  pp.  100-102). 

Rheumatic  Insanity  properly  so-called  (sub-acute,  or  chronic, 
or  vesanic  form  of  cerebral  rheumatism,  Bra) ;  Prolonged  rheu- 
matic encephalopathy  (Griesinger ;  Rheumatic  form  of  consecu- 
tive insanity  of  several  authors).  It  occurs  most  frecpiently  at 
the  termination  of  the  rheumatic  affection,  or  during  convalescence. 
Most  frecj^uently  it  is  announced  by  a  change  of  rJmracfer,  often 
coincident  Avith  the  diminution  of  the  articular  pains.  The 
patient  is  restless,  suspicious,  irascible,  and  suffers  from  insomnia. 

Visual  Hallucincdions  appear. — Those  of  the  other  senses  are  less 
frequent.  The  patient  believes  himself  surrounded  by  spies  and 
enemies ;  he  accuses  his  friends  and  relations,  believes  they  are 
killing  him,  sees  flames,  fancies  himself  in  a  furnace,  etc.  Thei-e 
a,re  then  periods  of  remission  and  exacerbation  which  alternate  in 
a  regular  manner. 

Sometimes  the  mental  aberration  assumes  the  maniacal  form ; 
then  there  are  excessive  loquacity,  extreme  animation,  restlessness, 
destructiveness,  noisiness,  bowlings,  hollow  eyes,  drawn  features  ; 
the  intellect  is  gxeatly  enfeebled,  the  speech  is  jerky,  and  there 
may  be  absolute  incoherence.  The  pulse  is  frecjuent,  the  tempera- 
ture normal,  or  nearly  so.  Sometimes  there  are  choreic  movements,^ 
spasms,  or  convulsions. 

In  the  great  majority  of  cases,  however,  the  mental  state 
assumes  the  melancholic  form.  The  patient  is  completely  prostrated, 
and  refuses  food ;  Avith  fixed  eyes,  he  is  self-absorbed,  and  appears  to 
be  overwhelmed,  does  not  speak,  and  seems  completely  uncon- 
scious of  what  is  taking  place  around  him. 

It  is  a  veritable  condition  of  stuporous  melancholia  (melancolie 
avec  stupeur). 


116  INDEX   OF  MENTAL   DISEASES, 

It  is  well  to  remark  that  in  chronic  rheumatic  insanity,  the 
general  symptoms  which  accompany  the  intellectual  troubles  are 
only  slightly  accentuated.  They  never  attain  the  violence  obser- 
ved in  cerebral  rheumatism,  properly  so-called  (Bra,  oj).  (if.,  pp. 
102-103). 

SENILE    INSANITY. 

Including:  (1,)  Senile  mania;  (2,)  Senile  melancholia;  (3,) 
Senile  dementia. 

I. — Senile  Mania  may  come  on  suddenly  or  slowly.  In  the. 
former  case,  an  initial  stage  of  stupidity  and  peculiarity  is  suc- 
ceeded "by  constant  talking,  shouting,  incoherence,  loss  of 
memory,  loss  of  attention,  sleeplessness,  and,  above  all,  by  a 
constant  motor  restlessness  by  night  and  day,  but  especially  hi/ 
riigJit"  (Clouston,  op.  cit.,  p.  573). 

In  the  latter  case  (the  attack  coming  on  slowly)  the  memory 
fails,  the  patient  becomes  stupid  and  confused,  then  suspicious, 
then  restless,  then  luimanageable,  then  violent.  The  speech  is 
senile ;  there  is  great  motor  restlessness,  especially  at  night 
(Clouston,  op.  cit.,  pp.  574-575). 

II. — Senile  Melancholia  begins  with  failure  of  memory, 
irritability,  exaggerated  opinions  of  self,  morbid  suspicions,  sleep- 
lessness, restlessness,  and  lack  of  self  control.  Afterwards,  slight 
transient  attacks  of  hemiplegia. 

As  in  the  other  forms  of  senile  insanity,  there  is  atheroma  of 
the  vessels,  the  radials  being  hard  and  cord-like,  and  the  temporals 
tortuous.  There  is  the  senile  speech  described  by  Clouston  (p.  568) 
as  "a  slight  indistinctness  of  speech,  a  want  of  motor  activity, 
and  perfect  co-ordination  in  the  articulatory  muscles,  a  change  in 
the  tone  of  the  voice  in  the  direction  of  feebleness,  a  difficulty  in 
finding  words,  a  tendency  to  stop  in  the  middle  of  sentences,  an 
omission  of  words,  especially  nouns " ;  a  "  mixture  of  aphasic, 
amnesic,  and  paretic  symptoms."  Afterguards,  there  is  complete 
loss  of  memory  for  recent  events.  There  are  fits  of  moaning, 
groaning,  and  tearless  weeping,  without  any  apparent  cause. 
There  are  at  times  sudden  suicidal  attempts  or  homicidal  attacks. 
All  the  worst  symptoms  come  on  at  night.  Clouston  would 
classify  as  melancholia  cases  where  there  are  the  outward  signs  of 
mental  pain  (p.  570).  Savage  [op.  cit.,  p.  202)  considers  that 
there  is  a  condition  of  painful  action  and  sensation,  such  as  may 
be  described  by  the  term  senile  melancholia.  "  It  appears  some- 
times rather  suddenly,  as  the  result  of  some  family  distress  or 
domestic  loss."  He  fiu-ther  says  (p.  20.3),  "I  saw  one  doctor 
who  suffered  from  constant  subjective  annoyances  through  his 
ears,  his  nose,  and  his  skin,  for  months  before  his  fatal  attack  of 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  117 

apoplexy.  In  some  other  cases  of  senile  melancholia,  mental  or 
bodily  hypochondriasis,  with  great  emotional  disturbance,  is  met 
with ;  and  it  is  not  unknown  for  patients  of  advanced  years  to 
destroy  themselves,  l^eing  convinced  they  have  outlived  their  time." 

III. — Senile  Dementia. — Sj)itzka  {op.  cit.,  p.  172)  considers 
this  to  be  the  only  characteristic  form  of  senile  insanity. 

According  to  him  the  symptoms  are,  increased  egotism,  penuri- 
ousness,  enfeeblement  of  memory,  especially  for  recent  events, 
unreasonable  prejudices,  frequently  profound  moral  deterioration, 
coarse  and  filthy  language  being  used,  and  filthy  or  intemperate 
habits  being  indulged  in.  In  addition  there  may  be,  esj^ecially  in 
males,  a  pathological  sexual  desire,  a  senile  satyriasis,  manifesting 
itself  in  indecent  assaults  on  girls  or  infants,  or  in  absurd  and 
ridiculous  marriage  plans.  Some  haA^e  unsystematisecl  ambitious 
delusions,  but  the  majority  have  depressive  delusions,  and  rare 
instances  are  on  record  where  senile  dements  have  committed 
suicide. 

The  most  common  delusions  relate  to  their  property.  They 
suspect  they  are  being  defrauded  or  robbed.  They  are  consequent- 
ly disposed  to  be  lachrymose,  and  to  evince  a  restless  and 
purposeless  activity.  Some  of  them  roam  about  at  night  continu- 
ously, either  purposelessly,  or  watching  for  thieves.  There  may 
be  hallucinations  and  illusions  of  a  painful  nature.  The  patient 
finally  becomes  fatuous,  and  may  be  voracious  and  dirty,  and  die 
with  apoplectiform  or  paralytic  symptoms.  In  addition  to  arterial 
sclerosis,  there  are  often  observable  a  marked  arcus  senilis, 
opacities  of  the  vitreous  body,  and  sometimes  cataract. 

Tremor  is  an  invariable  symptom.  Other  symptoms  which 
occur  in  some  cases  are  marked  hypersesthesia,  vertigo,  anorexia, 
paraparesis,  hemiparesis,  disturbances  of  speech,  and  epileiDtiform 
iittacks. 

SOMNAMBULISM  ( Pseitdo-Insanity  of). 
"  Most  bad  and  confirmed  sleep-walkers  have  a  neurotic  heredity, 
or  a  nervous  temperament,  or  both,  though  it  is  fortunately  quite 
certain  that  few  of  them  ever  become  insane.  Acts  of  violence, 
homicide  and  suicide  may  be  done  in  a  state  of  somnambulism  " 
(Clouston,  p.  608). 

STUPOR,    ANERGIC. 

Synonyms. — Acute  Dementia  ;  Acute  Primary  Dementia  ; 
Stuporous  Insanity  (Spitzka). 
Symptoms. — Prodromal :  Either  in  consequence  of  masturba- 
tion,    starvation,     or    exhausting    discharges    .(1,)     gradually 
increasing  apathy  and  want  of  energy,  or  (2,)  sudden  invasion 
a;fter  haemorrhage,  shock,  etc.  (Spitzka,  p.  159). 


118  INDEX   OF   MENTAL   DISEASES, 

Fully  developed :  A  loss  of  facial  expression ;  a  marked 
A'"aso-motor  paresis,  so  that  the  extremities  are  blue  and  cold ;  a 
lowering  of  the  trophic  energy,  so  that  sores  are  apt  to  form  and 
even  gangrene  may  occur  ;  the  reflex  functions  of  the  cord  are 
markedly  diminished,  and  the  higher  reflex  functions  of  the  brain 
almost  in  abeyance  ;  no  muscular  resistance  ;  no  delusions  ;  com- 
plete unconsciousness,  and  of  course  no  after  memory  of  events 
that  occurred  during  its  persistence  (Clouston,  p.  301). 

The  patient  is  in  a  state  of  immobility  and  does  nothing  of  his 
own  initiative.  Sensibility  is  impaired  as  much  as  mobility, 
so  that  even  the  cauteiy  may  not  be  perceived  by  the  patient. 
Food  to  be  swallowed  must  be  pushed  well  back  into  the  pharynx. 
The  pupils  are  dilated  and  react  poorly,  the  heart's  action  is 
greatly  enfeebled,  the  pulse  tardy,  small,  and  frequent,  the 
temperature  is  slightly  loAvered  and  the  extremities  are  cold, 
Avhile  adema  of  the  feet  is  constantly,  and  of  the  hands  and  face 
sometimes  observed  (Spitzka,  p.  159).  Wet  and  dirty  in  habits. 
The  saliva  dribbles  from  the  mouth.  Urine  rich  in  phosphates, 
and  physiological  discharges  of  skin  and  uterus  suppressed 
(Spitzka,  loc.  cit.). 

SYPHILITIC     INSANITY. 

Fournier  (Bra,  "Man.  des  Mai.  Ment.,"  p.  106)  refers  the 
clinical  types  of  cerebral  syphilis  to  six  forms,  viz.  :  the  cephal- 
algic,  the  congestive,  the  convulsive  or  epileptic,  the  aphasic,  the 
paralytic,  the  m-enial. 

MENTAL     FOEM. 

The  mental  form  (Bra,  oj).  cif.,  p.  110,  et  scq.)  is  most  frequently 
associated  with  A^arious  phenomena,  congestive,  epileptic, 
paralytic,  etc.,  but  it  may  exist  alone.  There  are  two  varieties, 
the  depressive  and  the  expansive. 

I. — Depressive   Variety. 

This  may  be  again  subdivided  into  simple  intellectual  depres- 
sion and  intellectual  depression  with  incoherence. 

(A,)  Simple  Depression. — This  is  a  form  of  intellectual  asthenia. 
The  power  of  attention  is  diminished  and  intellectual  operations 
are  less  rapidly  performed.  There  is  a  dulness,  a  slowness, 
a  laziness  of  ideation.  There  are  in  consequence  constant  mis- 
takes, awkwardness,  oversights,  and  forgetfulness.  The  patient 
is  vaguely  conscious  of  his  condition. 

At  the  same  time  there  is  a  progressive  change  in  his  character 
and  ha1)its,  and  there  is  an  unusual  inequality  of  temper. 


AVITH   THEIR   SYNONYMS   AND   SYMPTOMS.  119 

Amnesia  is  an  important  symptom.  It  may  come  on  gradually, 
interruptedly,  or  suddenly.  In  most  cases  the  defects  of  memory 
are  at  first  slight  and  insignificant,  but  they  gradually  increase, 
and  the  oversights,  errors,  and  omissions  become  more  frequent, 
until  a  veritable  amnesia  is  established,  the  memory  for  long 
past  events  alone  persisting. 

(B,)  Depression  toith  Incoherence. — The  patient  commences  a 
thing  and  does  not  finish  it  ;  forms  a  project  and  abandons  it ; 
rises  and  lies  down  without  knowing  why.  There  is  a  delusional 
state  which  is  general  and  non-systematised,  referring  to  all  the 
acts  of  life  and  not  to  one  in  particular,  and  without  any 
predominant  fixed  ideas. 

With  the  exception  of  momentary  attacks  of  excitement  the 
condition  is  calm  and  tranquil.  Occasionally  there  is  a  melan- 
cholic condition  with  somewhat  systematised  delusions ;  a 
persecutory  delusional  condition.  Still  more  rarely  thei"C  are 
cases  marked  by  suicidal  ideas. 

II. — Expansive  Vapjety. 

When  slight  the  patient  may  not  actually  be  insane,  but  merely 
the  subject  of  insanity  in  the  germ  (Fourniei').  The  patient  is 
then  exalted,  loquacious,  prone  to  exaggerate,  irritable,  unre- 
flecting. 

In  the  severe  form  there  is  a  true  maniacal  condition.  The 
facial  expression  is  wild  and  the  eyes  wander. 

There  is  motiveless  laughter ;  there  are  sudden  outbursts  with 
abusive  epithets,  menaces,  vociferations.  The  words  and  acts  are 
extravagant ;  there  is  constant  agitation  ;  unceasing  locjuacity. 
The  patient  becomes  indifferent  to  all  and  to  everything  ;  neglects 
his  affairs  ;  wanders  at  random  ;  dresses  and  undresses  without 
motive.  There  are  outbursts  of  dangerous  violence,  sometimes 
going  the  length  of  homicidal  attempts.  There  is  complete 
insomnia. 

There  are  observed,  though  rarely,  hallucinatory  phenomena  of 
various  kinds.  Where  the  delirium  is  a  concomitant  of  the 
epileptic  form  of  cerebral  syphilis  there  may  be  impulsive 
phenomena. 

.  SYPHILITIC  PSEUDO-GENERAL  PARALYSIS. 

Fournier  gives  as  the  principal  differences  between  this  and 
real  general  paralysis  : — 

(1,)  In  syphilis  the  intellectual  troubles  frequently  follow  one 
or  several  apoplectiform  or  epileptiform  attacks,  while  in  general 
paralysis  the  alteration  of  the  faculties  ordinarily  first  attracts 
attention. 


120  INDEX   OF   MENTAL   DISEASES, 

(2,)  Syphilitics  have  rarely  an  ambitious  expansive  delirium. 
They  are  embruted  ;  stupid  ;  sometimes  extravagant,  but  always 
relatively  humble  and  modest  in  their  delirious  conceptions. 

(3,)  Tremor  is  more  rarely  seen  in  syphilitics  ;  it  is  neither  so 
intense  nor  so  permanent ;  it  has  not  the  appearance  so  chai^acter- 
istic  of  the  tremor  of  the  lips  and  tongue  in  general  paralytics. 
In  general  paralysis  the  tremor  is  jerky  and  shifts  rapidly  from  one 
group  of  muscular  fibres  to  another.  There  is  also  very  fine 
fibrillary  tremor  often  requiring  close  scrutiny  for  its  perception. 

(4,)  In  syphilis  the  paralyses  are  much  more  accentuated  than 
in  general  paralysis.     Partial  joaralyses  are  more  frecjuent. 

(5,)  The  evolution  of  syphilitic  general  paralysis  is  less  regular 
than  that  of  ordinary  general  paralysis. 

(6,)  In  syphilis  there  is,  from  the  earliest  periods,  a  more  con- 
siderable alteration  of  the  general  condition  ;  there  is  often  a  very 
pronounced  cachexia. 

(7,)  The  lesions  differ.  In  syphilis  those  of  the  meninges  pre- 
dominate ;  in  general  paralysis,  those  of  the  cortex. 

(S,)  Cure,  possible  in  syphilis,  is  almost  impossible  in  ordinary 
general  paralysis. 

TOXIC     INSANITY. 

I.— ALCOHOLIC    INSANITY. 

A. — Acute    Alcoholic    Insanity. 

"  The  most  frequent  form  of  the  affection  is  (a,)  violent 
maniacal  delirium,  known  as  mania  a  potu,  with  a  tendency  to 
homicidal  acts.  In  some  cases  the  mental  disorder  takes  (h,) 
the  melancholic  form,  and  it  becomes  necessary  to  guard  specially 
against  the  strong  suicidal  tendency  which  generally  characterises 
it  "  (Sibbald,   "  Quain's  Diet.,"  vol.  i.,  p.  723). 

B. — Delirium  Tremens. 

(a,)  Ajyyretic. — The  onset  may  be  sudden  but  is  most  fre- 
quently preceded  by  a  prodromal  period  characterised  by 
preecordial  pain,  gasti'ic  irritability,  cephalalgia,  sensory  dis- 
turbances, hjq^ersesthesia,  hyperacousia.  Insomnia  is  almost 
always  present,  and  there  is  generally  a  condition  of  considerable 
depression. 

At  the  end  of  several  days  the  real  attack  commences  and 
is  marked  by  the  following  symptoms  :  Terrified  expression  ; 
injected  sunken  eyes ;  excessive  agitation.  Incessant  inco- 
herent babbling  difficult  to  understand,  yet  the  patient  may  at 
times  answer  pressing  questions  quite  pertinently.  Hallucinations 
soon  appear,  the  visual  being  most  frequent,  the  patient  seeing 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  121 

cats,  rats,  wild  beasts,  etc.  Sometimes  there  are  hallucinations 
of  hearing  or  of  the  general  sensibility  ;  there  are  buzzings  in  the 
ears,  sensations  of  burning,  pricking,  formication,  etc. 

The  hallucinations  have  certain  special  characters  :  (1,)  They 
appear  at  first  at  night.  Once  established  they  may  either  disappear 
in  the  daytime  to  re-appear  the  following  night,  or  they  may  be 
continuous.  When  disappearing  (during  recovery)  the}^  continue 
at  night  after  they  have  ceased  by  day;  (2,)  They  are  painful, 
often  aggressive,  the  moral  impressions  produced  by  them  varying 
from  astonishment  to  profound  terror.  All  the  patient's  sur- 
roundings seem  to  threaten  him.  The  fear  of  being  poisoned  is 
frequent  and  causes  the  refusal  of  food  which  is  so  often  trouble- 
some ;  (3,)  Their  mobility.  The  things  which  form  the  objects 
of  the  hallucinations  are  constantly  moving  and  displacing  each 
other  ;  hence  the  rapidity  of  ideas  and  actions  in  alcoholics  who 
are  quickly  by  turns  frightened,  anxious,  unquiet,  suppliant 
or  aggressive  (Magnan,  "  L'  Alcoolisme  et  son  action  sur  I'intelli- 
gence,"  p.  121). 

The  hallucinations  are  infinite  in  their  variety  but  they  often 
reflect  either  the  daily  occupations  or  the  predominant  pre- 
occupation of  the  moment,  with  a  special  preference  for  that 
which  is  painful  or  disagreeable.  The  patient  may  fancy  he 
hears  abusive  epithets,  or  the  voices  of  his  relations  and  friends  ;  or 
he  may  see  his  wife  surrounded  by  people  who  are  outraging  her 
before  his  eyes,  or  he  may  fancy  himself  in  prison,  before  a 
tribunal,  etc.,  etc.  The  condition  may  be  maniacal,  melancholic, 
or  stuporous,  the  first  form  being  the  most  frecjuent  (Magnan, 
op.  (it.,  pp.  122-124). 

Perversions,  illusions,  and  hallucinations  of  the  senses  of  taste 
and  smell  are  less  frequent  than  those  of  the  other  senses,  but 
occur  occasionally. 

The  visual  hallucinations  develop  from  obscurity  of  vision, 
sparks,  flames,  shades,  etc.,  to  grinning  faces,  animals,  etc. 

The  auditory  hallucinations  from  hummings,  buzzings,  and 
whistlings  to  voices  and  tumultuous  cries.  They  disappear  in 
the  same  order  and  at  first  in  the  daytime  then  at  night,  and  a 
prolonged  and  c|uiet  sleep  terminates  the  attack.  In  some 
individuals  amelioration  is  less  rapid  and  regular,  sleep  is  dis- 
turbed, there  is  irritability,  and  there  are  vague  ideas  of  persecu- 
tion. In  yet  other  cases  delirious  conceptions  giving  rise  to 
suspicions,  jealousy,  and  misery  remain  after  the  acute  symptoms 
have  subsided,  and  these  cases  furnish  many  examples  of  suicide 
and  homicide  (Magnan,  op.  cit.,  pp.  125-128). 

Two  or  three  cases  under  my  care  (not  in  asylums)  have  been 
free  from  actual  visual  hallucinations,  but  have  suffered  from 


122  INDEX   OF   MENTAL   DISEASES, 

visual  illusions,  such  as  taking  lamposts  for  policemen,  and  red 
letter-])oxes  for  soldiers.  In  these  cases,  auditory  hallucinations 
and  illusions  were  well  marked,  the  patients  hearing  whisperings, 
shoutings,  and  abusive  and  threatening  language  when  there  were 
no  sounds  whatever,  and  construing  nearly  every  real  noise  into 
a  reproach  or  a  threat. 

One  patient,  a  medical  man,  a  passenger  on  board  ship,  gave 
me  the  first  indication  of  his  contlition  a  few  hours  after  joining 
the  ship  by  taking  me  down  to  hear  what  he  called  the  "  death 
watch "  ticking  ;  afterwards  he  became  quite  delirious,  and,  on 
his  recovery,  told  me  he  fancied  he  was  going  to  be  killed  during 
his  excitement,  and  that  the  engines  kept  constantly  saying, 
"  Waiting  for  the  doctor,"  "  Waiting  for  the  doctor,"  "  Waiting 
for  the  captain,"  "AVaiting  for  the  captain  "  (auditory  illusions). 
A  coloured  man,  who  passed  his  cal)in  door  when  it  was  open,  he 
took  to  be  the  devil.  He  had  other  visual  illusions,  but  no  actual 
visual  hallucinations. 

Tremor  may  be  general  or  localised,  transitory  or  persistent, 
slight  or  intense.  If  local,  transitory,  and  slight,  the  disease  is 
mild  ;  if  intense,  general,  and  persistent,  not  disappearing  during 
sleep,  accompanied  by  shudderings,  slight  muscular  shocks  and 
muscular  undulations,  on  the  second  or  third  day  nervous  ex- 
haustion sets  in.  These  muscular  twitchings  and  undulations  are 
more  frequently  observed  in 

(b,)  Pyretic  delirium  tremens  :  and  if  not  perceptible  visually, 
should  be  sought  for  digitally. 

Fever  and  tremor  ordinarily  co-exist,  but  in  some  cases  the 
former  is  very  high,  with  very  little  of  the  latter  (Magnan, 
"  Influence  de  I'Alcoolisme  sur  les  Maladies  Mentales,"  p.  7).  In 
mild  cases,  owing  to  agitation,  the  temperature  may  rise  to  101° 
or  101-4°  F.  (taken  in  rectum),  sinking  during  temporary  quietude 
to  100-2°.  In  grave  cases  the  temperature  will  oscillate  round 
102-1°  for  two  or  three  days,  and  then  rise  to.  105-8°  (op.  at, 
p.  6).  Febrile  or  pyretic  delirium  tremens  is  marked  there- 
fore by  fever,  severe  muscular  tremor,  and  muscular  feebleness, 
and  occurs  almost  always  in  consequence  of  recent  and  numerous 
alcoholic  excesses. 

(c,)  Complicating  Delirium  Tremens  manifests  itself  in  the 
chronic  alcoholic  who  is  accidentally  attacked  by  some  disease, 
or  who  suffers  some  mechanical  injury.  The  fever  follows  the 
course  pertaining  to  the  intercurrent  affection,  Avhether  pneu- 
monia, erysipelas,  pericarditis,  or  other  disease,  or  accidental  or 
therapeutical  traumatism  (Magnan,  q;?.  cit.,  p.  7). 

The  other  alcohoHc  phenomena  present  very  different  degrees 
of  intensity.     Thus,  the  delirium  ma}^  betray  itself  by  nocturnal 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  123 

hallucinations  and  nightmares  only.  The  motor  troubles  are  very 
frequently  limited  to  tremor,  more  or  less  extensive,  of  the  hands, 
or  of  the  arms  and  legs,  of  the  arms  alone,  of  the  legs  and  face. 
There  is  an  absence  of  the  deep-seated  general  muscular  tremor 
of  febrile  delirium  tremens  (Magnan,  op.  cif.,  p.  8). 

In  severe  attacks  of  delirium  tremens,  the  nervous  exhaustion 
and  muscular  feebleness  may  proceed  to  incomplete  paralysis  of 
the  arms  and  legs  ;  there  may  be  embarrassment  of  speech,  simu- 
lating that  of  genei^al  paralj^-sis ;  profuse  sweats,  exhaling  an 
alcoholic  odour ;  the  urine  is  scanty,  the  pupils  are  sometimes 
unequally  contracted  ;  the  pulse  is  small,  often  accelerated  (Bra, 
op.  cU.,  pp.  143-144). 

C. — Chronic  Alcoholic  Insanity. 

The  passage  to  the  chronic  state  does  not  in  general  folloAv  a 
regular  progression,  but  is  made  by  leaps,  and  is  accompanied  by 
exacerbations,  which  Lasegue  described  under  the  name  of 
"sub-acute  alcoholism."  Between  the  transient  phenomena  of 
frequently-repeated  intoxication  and  the  establishment  of  in- 
sanity there  is  an  intermediate  period  of  irritabilit}',  inquietude, 
and  impressionability. 

Precursory  Sijrnjjtoms. — Insomnia  more  and  more  pronounced, 
tremor  of  the  hands,  dreams,  and,  in  a  more  advanced  stage, 
hallucinations  (Bra,  oj).  cif.,  p.  148).  The  hallucinations  have 
the  three  characters  described  under  the  head  of  "Delirium 
Tremens,"  i.e.,  they  are  nocturnal,  mobile,  painful. 

Visual  Hcdlucinations. — The  patient  fancies  he  sees  unclean 
animals,  thieves,  assassins,  etc. ;  he  -witnesses  heartrending  scenes  ; 
sees  himself  in  the  midst  of  flames,  at  the  scaffold,  etc. 

Auclitori/  Hullnciiiutions. — He  believes  he  hears  abusive  epithets, 
threats,  accusations  against  his  honour  and  morality;  he  hears 
groanings,  lamentations,  cries,  the  clash  of  arms,  etc. 

Olfactorji  Hallucinations. — He  fancies  he  perceives  most  disagree- 
able stenches  and  suffocating  odours;  that  he  breathes  a  pestilent 
atmosphere,  etc. 

Gh.istatonj  Hallucinations. — He  fancies  he  tastes  all  sorts  of 
nauseating  substances,  as  well  as  poisons. 

Tactile  Hallucinations. — He  believes  he  is  suffering  terrible 
punishments  ;  he  feels  knife-blades  enteiing  his  flesh  and  mutilat- 
ing him  friglitfully;  he  feels  the  crawling  of  a  serpent,  which 
glides  over  his  skin  and  enfolds  him  ;  he  feels  insects  and  worms 
gnawing  his  body,  which  he  fancies  he  sees  falling  in  shreds  ; 
swarms  of  flies  appear  to  him  to  enter  his  mouth,  nostrils,  and 
eyes ;  or  he  even  fancies  he  is  drowned  or  throAvn  down  a 
precipice. 


124  INDEX   OF   MENTAL   DISEASES, 

Under  the  influence  of  these  halhicinations,  the  patient  reacts 
variously ;  he  becomes  excited  and  defends  himself,  threatens,  or 
strikes ;  or  he  may  even  remain  immoA'able,  overwhelmed, 
crushed.  Hence  his  different  attitudes,  maniacal,  melancholic,  or 
stuporous,  all  arising  from  the  same  cause,  but  A^arying  according 
to  the  degTee  of  intensity  of  this  cause.  There  is  a  successive 
gradation  in  the  development  of  these  phenomena.  The  mere 
functional  troul)le  passes  into  the  illusion,  and  this  into  the  con- 
fused hallucination — at  first  simple,  then  multiple  (compound), 
and  becoming  more  and  moi'e  precise,  neat,  and  distinct,  simu- 
lating reality. 

AVhen  amelioration  is  taking  place,  the  phenomena  disappear 
gradualh^,  in  accordance  with  an  analogous  decreasing  order ;  the 
distinct  hallucination  fades  into  the  confused  one,  the  latter  into 
the  illusion,  and  this  again  into  the  mere  functional  disturbance. 
Such  is  the  usual  method  of  evolution  and  involution  of  alcoholic 
hallucinatory  phenomena ;  although  exceptionally  they  ma}^  at 
once  reach  their  acme  (Magnan,  "  Influence  de  I'Alcoolisme  sur 
les  Maladies  Mentales,"  p.  9). 

As  the  disease  progresses,  all  the  psycho-sensorial  phenomena 
gradually  lose  any  acuteness  which  they  possess  ;  the  moral  and 
affective  faculties  and  the  ^yiY[  of  the  patient  become  considerably 
weakened,  and  the  individual  abandons  himself  entirely  to  the 
caprice  of  his  instincts.  After  a  long  series  of  excesses,  the 
intelligence  is  absolutely  annihilated,  and  the  patient  falls  into  a 
state  of  complete  dementia  (Bra,  oj).  cif.,  p.  151). 

SjDitzka,  Avriting  of  Chronic  Alcoholic  Insanity  ("Insanity," 
p.  252),  observes  that  the  alcoholic  tremor  is  the  most  important 
and  constant  somatic  sign,  and  that  it  is  best  seen  in  the 
hands,  tongue,  and  lips ;  he  also  says  it  has  the  peculiarity 
that  it  dec/rases  under  the  influence  of  alcoholic  beverages,  and  is 
most  marked  when  the  patient  is  perfectly  sober. 

AVhen  intoxication  is  prolonged  either  sloAvly  and  progressively, 
or  by  means  of  several  relapses  AAdth  acute  accidents,  there  remain 
certain  delusions,  hypochondriacal  ideas,  illusions,  and  sometimes 
even  hallucinations,  AAdiich  reflect  the  general  characters  of  the 
intellectual  and  sensory  disturbances  of  the  earlier  periods,  but 
Anthout  their  acuteness  or  actiAdty.  Chronic  alcoholics  may  have 
melancholic  delusions  and  suicidal  ideas,  but  these  are  only  the 
outline  of  the  initial  phenomena.  Some  patients,  AAdth  or  AA'ithout 
rencAved  excesses,  become,  at  irregular  periods,  semi-maniacally 
excited,  turbulent,  and  destructive,  and  act  in  every  sense  auto- 
matically (Magnan,  "LAlcoolisme,"  etc.,  j).  130). 

In  some  cases,  after  the  acute  symptoms,  certain  delusiA^e  con- 
ceptions emanate  from  the  hallucinations,  and  give  rise  to  jealousy 


WITH   THEIR   SYNOxVYMS   AND   SYMPTOMS.  125 

and  suspicion.  In  other  cases  troubles  of  the  general  sensi- 
bilitj''  remain,  accompanied  by  hypochondriacal  ideas  and  fears  of 
being  poisoned  (Magnan,  "L'Alcoolisme,"  etc.,  p.  128). 

"  The  persecutory  delusions  of  alcoholism  relate  to  the  sexual 
organs,  to  the  sexual  relations,  and  to  poisoning.  This  fact  is  so- 
constant  a  one,  that  the  combination  of  a  delusion  of  mutilation 
of  the  sexual  organs  with  the  delusion  that  the  patient's  food  is 
poisoned,  and  that  his  wife  is  unfaithful  to  him,  may  be  considered 
to  as  nearly  demonstrate  the  existence  of  alcoholic  insanity  as 
any  one  group  of  symptoms  in  mental  pathology  can  prove  any- 
thing. With  this  there  are  unpleasant  hallucinations. 
Delirious  exacerbations  are  likely  to  occur  in  consequence  of  the 
patient's  morbid  fear,  and  in  brutal  fury  he  may  hack  the  wife 
whom  he  suspects  of  infidelity  to  pieces "  (Spitzka,  "Insanity," 
p.  254). 

Magnan  ("L'Alcoolisme  et  son  action  sur  I'lntelligence," 
pp.  131-132)  says,  in  chronic  alcoholism  (chronic  alcoholic 
insanity),  the  memory  is  enfeebled,  the  judgment  is  less  sound 
and  is  incapable  of  discernment,  the  imagination  is  extinguished, 
the  power  of  associating  ideas  is  much  lessened,  giving  rise  to 
incoherence  ;  the  moral  sensibility  is  blunted.  Apathetic,  indif- 
ferent, stupid,  the  chronic  alcoholic  has  no  care  for  his  person, 
and  no  thought  for  his  family.  In  the  last  periods  intelligence  is 
annihilated ;  insensibly  all  the  delirious  flights  disappear,  the 
hypochondriacal  preoccupations  and  the  sensory  troubles  fade 
away  little  by  little.  Sometimes  a  false  sensibility  (sensiblerie). 
analogous  to  that  of  apopletic  elements,  supervenes. 

There  are  frequently  also  "  stunnings,"  vertigo,  apoplectiform 
and  epileptiform  attacks,  and  partial  paralysis,  corresponding  to 
the  lesions  of  the  nervous  centres,  discovered  post-mortem. 

D. — Alcoholic  P.seudo-General  Paralysis. 

This  affection  attacks  by  preference  those  in  whom  alcoholic 
excesses  are  rarely  accompanied  hy  well  marked  intellectual  dis- 
turbances, but  rather  by  profound  somatic  perturbations.  It 
resembles  real  general  paralysis  so  nearly  as  to  be  easily  mistaken 
for  that  disease.  It  commences  brusquely,  and  quickly  attains 
its  apogee,  breaking  out  usually  after  an  attack  of  sub-acute 
alcoholism.  There  is  embarrassment  of  speech,  which  occupies 
a  secondary  place,  and  tends  to  disappear  rapidly.  The  pupils 
are  unequal,  and  very  little  sensible  to  the  influence  of  light. 

The  tremor  is  general  and  massive.  The  paralysis  is  incom- 
plete, and  commences  at  the  distal  extremities  of  the  limbs. 

There  are  symptoms  of  alcoholic  intoxication ;  disturbances  of 
sensibility,  anaesthesise,  hypersesthesise,  risual  hallucinations.  Some- 


126  INDEX   OF  MENTAL   DISEASES, 

times    there   are   epileptiform   attacks,    gastric    embarrassment, 
anorexia. 

The  tendency  to  ameliorate  soon  shows  itself  ;  the  patient  often 
recovers  from  his  attack,  but  soon  falls  into  excesses  causing  an 
almost  fatal  relapse  (Bra.  op.  cit.,  pp.  137-139). 

E. — Combined   Alcoholic   Dementia   and   Alcoholic 
Paralysis. 

A  form  of  combined  alcoholic  dementia  and  alcoholic 
paralysis  which  occurs  mostly  in  females — in  them  to  a  certain 
extent  taking  the  place  of  delirium  tremens  in  men  (Blandford 
"Insanity,"  1st  ed.,  pp.  65  and  278-279). 

After  years  of  habitual  drinking,  quite  suddenly,  without 
illness,  sleeplessness,  or  excitement,  memory  gives  way.  Muscu- 
lar power  and  co-ordination  are  lost,  but  the  weakness  does  not 
extend  to  the  organs  of  articulation.  "  The  delusions  of  such 
patients  chiefly  depend  on  the  entire  obliteration  of  memory. 
The  patients  want  to  see  and  visit  people  who  have  long  since 
died  ;  and  when  told  of  this,  Avhen  the  circumstances  are  brought 
back  to  their  recollection,  they  make  the  same  request  fiA^e 
minutes  after." 

II.— INSANITY   FROM   ABSINTHE   AND    ALCOHOLIC 
PREPARATIONS   OF  ABSINTHE. 

In  absinthe  drinkers  the  hallucinatorj'-  phenomena  reach  their 
acme  suddenly  (Magnan,  Infi.  de  I'Alc,  etc.,  p.  9).  In  a  general 
way  the  hallucinatory  phenomena  are  similar  to  those  of  alcohol, 
difiering  only  in  the  suddenness  of  their  onset.  In  addition  to 
the  tremor,  there  are  epileptic  seizures,  which  are  seldom 
observed  in  uncomplicated  alcoholic  cases  (Magnan,  "Infi.  de 
I'Alc,"  etc.,  pp.  4-5). 

A  small  dose  of  essence  of  absinthe  injected  into  the  veins  of 
dogs  causes  vertigo  and  muscular  twitchings ;  a  large  dose, 
epileptic  attacks  and  delirium. 

During  the  first  stage  of  the  absinthic  attack  (in  dogs)  the 
pupils  are  dilated  and  the  papillae  and  fundi  oculorum  are 
injected  (Magnan,  "  Physiologie  Pathologique  et  Recherches 
Cliniques,"  p.  113). 

HI.— INSANITY  FROM  OPIUM  OR  ITS  ALKALOIDS. 

Clouston  (op.  cit.,  p.  445)  says,  "  I  have  seen  many  cases  of 
insanity  residting  from  opium-eating,  and  one  from  the  hypoder- 
mic  use   of   morphia.     These  were   very   like   the   insanity    of 


WITH   THEER   SYNONYMS   AND   SYMPTOMS.  127 

chronic  alcoholism,  but  not  so  suicidal,  with  greater  weakness  of 
the  heart's  action,  and  more  sleeplessness,  sickness,  and  intoler- 
ance of  food  for  the  first  fortnight." 

Savage  ("Insanity,"  p.  430)  believes  that  the  opium  crave  is 
stronger  than  any  other.  He  states  that  symptoms  resembling 
delirium  tremens  may  be  set  up  by  opium  eating  or  the  injection 
of  morphia,  and  mentions  the  fact  that  it  has  been  said  that  a 
morphia  injection  will  quiet  in  morphismus,  but  alcohol  Avi  11  cause 
excitement.  There  are  present  the  same  tremor,  want  of  appetite, 
refusal  of  food,  ideas  of  poison,  hallucinations,  and  tendency  to 
erotic  ideas.  Chronic  morphismus  may  also  be  set  up  with 
suspiciousness,  auditory  hallucinations,  feelings  of  galvanic  shocks. 

Cocaiuonmiiia  is  a  form  of  excitement  caused  by  the  abuse  of 
cocaine,  generally  in  conjunction  with  morphia. 

IV.— INSANITY  FROM  CHLORAL. 

Clouston  (loc.  cit.)  says,  "  I  have  seen  two  cases  of  insanity 
brought  on  by  the  use  of  chloral.  They,  too,  were  of  the  same 
generic  type  as  the  alcoholic  cases,  and  demanded  the  same  treat- 
ment." 

Savage  (oj).  cit.,  p.  429)  states  that  chloral  will  give  rise  to  a 
crave,  a  sleepless  habit,  a  feeling  of  deep  depression,  most  marked 
on  awaking  in  the  morning ;  this  feeling  is  associated  with 
anxiety  and  a  hypochondriacal  feeling  at  the  epigastrium.  It 
may  produce  very  great  emotional  disturbance  and  irritability, 
passing  into  deep  melancholia,  with  suicidal  tendencies.  It  pro- 
duces loss  of  control  and  tendency  to  impulses,  and  thus  causes 
suicide  or  homicide. 

v.— INSANITY  FROM  CANNABIS  INDICA. 

This  drug  when  taken  habitually  for  a  lengthened  period  pro- 
duces a  form  of  excitable  mania  with  delusions,  from  which  the 
patients  for  the  most  part  recover.  These  cases  are  common  in 
India  (Blandford,  "Insanity  and  its  Treatment,"  1st  ed.,  p.  66). 

VI.— INSANITY  FROM   LEAD.     SATURNINE  INSANITY. 

A. — Delirious  Form. 

Precursory  Symphnm. — In  the  great  majority  of  cases  it  is  pre- 
ceded by  j)hysical  symptoms  of  saturnine  intoxication,  blue 
gingival  line,  colic,  etc.  The  commencement  of  the  attack  is 
rarely  sudden,  but  is  generally  announced  by  cejjhalalf/ia,  depression, 
acceleration  of  the  jmlse,  insomnia  ;  sometimes  by  ocular  troubles 
vertigo,  tremor. 


128  INDEX    OF   MENTAL   DISEASES, 

Deceloptd  Stage. — This  form  of  insanity  is  sometimes  devoid  of 
special  characteristics,  at  other  times  the  state  is  one  of  («,)  acute 
vwnia,  with  furious  and  more  or  less  continuous  delirium,  with 
incoherence,  extreme  agitation,  ahudve  vociferations,  and  every 
sort  of  violence.  In  some  cases  the  condition  is  one  of  {!),) 
melancholia,  either  continuous  or  interrupted  by  periods  of  exal- 
tation. Visual  and,  more  rarely,  auditory  hallucinations  appear. 
The  loss  of  memory  is  often  complete.  It  sometimes  happens 
that  (c,)  dementia  is  suddenly  established  at  first,  without  the 
physical  saturnine  symptoms  being  such  as  to  lead  one  to  expect 
such  an  occurrence. 

B. — Comatose  Form. 

It  may  show  itself  at  first,  or  appear  after  the  delirious  form  or 
after  an  epileptiform  attack.  In  general  the  coma  is  not  very 
pronounced.  It  is  a  sort  of  somnolence,  disturbed  by  fits  of 
agitation,  automatic  movements,  and  cries.  The  patient  replies 
in  a  confused  and  evasive  manner  to  questions,  and  then  falls 
again  into  his  torpid  state.  Little  by  little  the  patient  comes  to 
himself,  without  remembering  Avhat  has  happened. 

C. — Convulsive  Form. 

Saturnine  convulsions  have  an  extreme  analogy  with  epileptic 
attacks.  There  is,  however,  no  aura.  They  begin  by  a  sudden 
loss  of  consciousness,  are  of  long  duration,  and  terminate  in  an 
intellectual  obtusion ;  a  state  of  profound  somnolence,  which 
lasts  till  the  outbreak  of  a  fresh  attack. 

D. — Mixed  Form. 

It  presents  successively  all  the  forms  already  described,  melan- 
cholic, maniacal,  convulsive,  comatose. 

E. — Saturnine  Pseudo-General  Paralysis. 

It  commences  su.ddenly  and  noisily.  It  at  once  attains  its 
acme.  The  embarrassment  of  speech  is  sometimes  so  marked  at 
the  commencement  that  the  voice  is  unintelligible.  It  is  a  true 
stammering.  There  are  symptoms  of  saturnine  intoxication  ; 
blue  line  on  gums,  earthy  hue  of  skin,  acute  cephalalgia,  stunnings, 
cramps,  formications,  various  neuralgia?,  anaesthesise,  partial 
hypersesthesiae,  arthropathies,  paralyses,  epileptic  or  eclampsic 
troubles.  The  patients  are  subject  to  insomnia  and  nightmare. 
Visual  hallucinations  and  ideas  of  persecution  and  poisoning- 
intermingle  with  the  delirium. 

The  pupillary  inequality  is  more  often  absent  t.han  in  general 
paralysis. 


WITH   THEIR   SYNONYMS   AND    SYMPTOMS.  129 

The  tremor  is  more  intermittent,  more  pronounced,  and  more 
spasmodic  than  in  general  paralysis. 

The  patients  are  often  dirty  and  completely  paralysed  on  their 
entry  into  the  asylum. 

The  dementia,  which  manifests  itself  suddenly  in  its 
greatest  intensity,  is  much  more  apparent  than  real.  It  is 
a  suspension  rather  than  an  abolition  of  the  intellectual 
faculties.  The  tendency  to  amelioration  makes  itself  rapidly 
felt,  the  intellect  sometimes  waking  up  at  the  end  of  a  very  short 
period  (Bra,  op.  cit.,  pp.  131-134). 

VII.— INSANITY  FROM  MERCURY. 

Generally  preceded  and  accompanied  by  the  mercurial  cachexia. 

The  symptoms  of  chronic  mercurial  poisoning  as  it  affects  the 
central  nervous  system  are,  according  to  Naunyn,  great  mental 
irritability,  extraordinary  terror,  perplexity,  anxiety,  sleeplessness, 
and  tendency  to  suffer  from  Hallucinations  ("  erethismus  mer- 
curialis  ").  At  the  same  time  there  are  symptoms  of  mercurial- 
ismus  (anaemia,  gastro-intestinal  catarrh,  salivation,  tremor). 
Mania,  melancholia,  or  mental  enfeeblement  may  develop  out  of 
this  condition  (Krafft-Ebing,  op.  cit.,.  p.  224). 

Cocaine,  salicylic  acid,  iodoform,  and  ergot  sometimes  give  rise 
to  hallucinatory  delirium.  Ilyoscyamus,  conium,  stramonium, 
belladonna,  poisonous  fungi,  chloroform,  and  paraldehyde 
occasionally  cause  mental  disturbances.  The  prolonged  use  of 
large  doses  of  the  bromides  may  result  in  mental  and  muscular 
weakness,  loss  of  throat  reflex,  amnesic  aphasia,  stammering- 
speech,  staggering  gait,  cachectic  pallor,  tremulousness,  etc. 
Poisonous  gases,  e.g.,  carbon  monoxide  and  the  vapour  of  carbon 
disulphide  may  cause,  when  habitually  inhaled,  headache  and 
vertigo,  followed  by  transitory  mania  or  melancholia  and  then 
mania.  Cerebral  symptoms  may  be  occasioned  by  autogenous 
poisoning  (uraemia,  acetonaemia,  cholsemia).  The  cachexia 
strumipriva  (anaemia,  cachexia,  and  mental  torpor  following  extir- 
pation of  the  thyroid  in  young  persons)  is  worthy  of  note 
(Krafft-Ebing,  loc.  cit.).  Morselli  in  his  classification  includes 
pellagrous  insanity  under  the  head  of  the  "toxic  encephalo- 
pathies "  {op.  cit.,  p.  437).  He  gives  pellagrous  pseudo-general 
paralysis,  carbonic  oxide  pseudo-general  paralysis,  etheric  insanity, 
lathyrism,  and  nicotism  (smokers'  dementia)  in  addition  to  many 
of  the  forms  above-mentioned. 

TRAUMATIC   INSANITY. 

Spitzka  (p.  371)  and  Clouston  (p.  414)  say  that  insolation 
causes  a  form  of  insanity  very  much  like  that  due  to  traumatism. 

9 


130  INDEX   OF   MENTAL  DISEASES, 

Spitzka  further  states  that  it  is  far  more  likely  to  lead  to  general 
paralysis  than  is  traumatism.  He  also  observes  that  radiant  heat 
(artificial)  acts  in  a  similar  way  to  sunstroke.  Head  injuries  may 
originate  an  ordinary  attack  of  insanity  in  a  person  predisposed 
to  the  disease  (Clouston,  p.  417). 

Whilst  fractures  of  the  skull,  with  depression,  are  more  likely 
to  lead  to  serious  mental  mischief,  yet  even  simple  concussion 
may  induce  chronic  incurable  insanity,  or  the  disposition  to  it. 

Directly  after  an  injury,  and  intercurrent  with  the  stupor  and 
coma  following  shock,  delii'ium,  hallucinations,  and  excitement 
often  manifest  themselves.  Or  there  may  be  serious  lacuna  of 
the  memory,  the  patient  either  recovering,  or  passing  into  a  con- 
dition very  similar  to  primary  mental  deterioration.  But  the 
true  traumatic  insanity  comes  on  some  time  after  the  injury  to 
the  head  (Spitzka,  "  Insanity,"  p.  370). 

Spitzka  further  writes  (p.  371),  "The  subjects  of  this  disorder 
are  noticed  to  undergo  a  change  of  character,  to  exhibit  a 
tendency  to  alcoholic  excesses,  to  become  morally  j^erverse, 
suspicious,  brutal,  and  quarrelsome,  and  to  manifest  murderous 
or  other  violent  impulses,  occasionally  associated  with  fits  of 
maniacal  self-exaltation  or  furor,  usually  of  short  duration.  This, 
condition  is  remarkable  for  its  long  duration  and  its  frequent  and 
sudden  changes,  the  occasional  lucidity  of  the  patients  being 
accompanied  at  the  time  by  hypochondriasis.  As  a  rule,  pro- 
gressive deterioration  sets  in,  and  dementia  terminates  the 
history  of  the  case.  Tinnitus  aurium,  photopsia,  scintillation 
before  the  eyes,  headache  of  a  pulsatory  or  grinding  character, 
vertigo,  paresis  of  various  muscular  groups,  particularly  of  the 
eyeball,  without  fibrillary  tremor,  anaesthesias,  and  hyper- 
sesthesias,  as  well  as  insomnia,  are  frequent  accompaniments,  and 
some  of  these  enumerated  signs  are  present  in  every  case." 

Clouston,  speaking  of  the  more  characteristic  type  of  trau- 
matic insanity,  says  ("Ment.  Dis.,"  p.  414),  "It  is  accompanied 
by  motor  symptoms,  either  in  the  shape  of  speech  diflficulties,. 
slight  hemiplegia,  general  muscular  weakness,  or  convulsions. 
Usually  in  such  cases  there  are,  in  addition,  sensory  symptoms,, 
such  as  cephalalgia,  vertigo,  hallucinations,  a  feeling  of  confusion 
and  incapacity  for  exertion  of  any  kind,  mental  or  bodily.  The 
mental  symptoms  are  usually  a  form  of  melancholia  at  first, 
tending  in  time  towards  an  irritable  and  sometimes  impulsive  and 
dangerous  dementia  or  delusional  insanity.  In  my  experience 
such  cases  are  all  absolutely  intolerant  of  alcoholic  stimulants,. 
a  very  little  of  which  will  always  make  them  maniacal,  and  often 
very  dangerous  and  even  homicidal.  Many  of  them  have  a. 
craving   for   stimulants,    too,    which   they   indulge,    and    which 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  131 

aggravates  all  these  symptoms."  He  further  states  that  a  few 
cases  become  ordinary  epileptics.  He  also  recommends  that  in 
all  traumatic  cases  the  condition  of  the  ui-ine  as  to  sugar  and 
albumen  should  be  carefully  tested. 

Traumatism  is  one  of  the  rare  causes  of  general  paralysis,  and 
Spitzka  observes  (p.  370)  that  the  prodromal  period  of  cases  so 
caused  is  apt  to  be  marked  1)y  the  "furious  outbreaks  and 
murderous  impulses  characteristic  of  what  might  be  called  the 
traumatic  neurosis." 

UTERINE,  OR  AMENORRH(EAL  INSANTIY. 

Of  the  cases  arising  from  disordered  or  suspended  menstrua- 
tion, nearly  tv/o-thirds  are  melancholic  in  character,  and  nearl}' 
one-third  maniacal,  a  few  are  stuporous,  and  a  few  delirious. 

Occasionally,  but  very  rarely,  acute  delirious  mania  may  be 
induced  in  a  young,  fidl-blooded,  healthy  woman  of  nervous 
.heredity  by  the  suppression  of  menstruation. 

Stupor  is,  hoAvever,  more  common  than  acute  delirium  as  a 
mental  result  of  suppressed  menstruation  in  young  women  of 
nervous  heredity. 

In  the  melancholic  cases,  hallucinations  of  hearing  of  a  dis- 
agreeable character  may  develop  (Clouston,  "  Ment.  Dis.,"  p.  473 
et  seq.). 

YOUNG  CHILDREN   (Delirium  of). 

"  In  most  cases  it  is  a  pure  delirium,  mthout  consciousness, 
attention,  or  memory,  but  in  some  instances  there  are  frightful 
hallucinations  ;  in  others  an  excited  melancholia  of  short 
duration,  with  violent  screaming,  tearless  weeping,  and  all  the 
usual  signs  of  mental  depression  "  (Clouston,  p.  606). 

Grouping  of  the  foregoing  forms  of  Mental  Aberration 

ACCORDING   to   ONE   OR   TWO    OF   THE   MOST   PROMINENT 
SYMPTOMS. 

I. — Mental  pain,  or  hindrance  (hampering)  of  mental  action,  or 
both. — Abdominal  diseases,  insanity  of ;  anaemic  insanity ;  cataleptic 
insanity  ;  choreic  insanity,  some  cases  ;  circular  insanity,  melan- 
choly phase  ;  climacteric  insanity  ;  insanity  from  deprivation  of 
senses ;  diabetic  insanity ;  gestational  insanity,  most  cases ; 
hysterical  insanity,  some  cases ;  katatonia,  one  phase  in  most 
cases ;  lactational  insanity,  most  cases ;  melancholia,  simple, 
agitated,  suicidal ;  masturbational  insanity,  second  stage  ;  meta- 
static insanity ;  neurasthenic  insanity  ;  oxaluria  and  phosphaturia, 
insanity  of  ;    paralysis  agitans,  insanity  of  ;    pellagrous  insanity  ; 


132  INDEX  OF  llENTAL  DISEASES, 

periodical  melancholia  ;  podagrous  insanity,  some  cases  ;  post- 
connubial  insanity  ;  pubescent  insanity  ;  puerperal  melancholia  ; 
saturnine  and  mercurial  insanity,  some  cases  ;  uterine  insanity, 
nearly  two-thirds  of  cases;  delirium  of  young  children,  some 
cases  ;  rheumatic  insanity,  most  cases. 

II. — Emotional  exaltaiion,  or  excitement  (mental  and  riiotoi'),  or 
loth. — Adolescent  insanity  ;  choreic  insanity,  some  cases  ;  circular 
insanity  (maniacal  phase) ;  post-febrile  consecutive  insanity,  some 
cases  ;  inflammatory  consecutive  insanity  :  epileptic  insanity  ; 
insanity  of  exophthalmic  goitre  ;  gestational  insanity,  a  few  cases ; 
acute  hysterical  insanity,  most  cases  ;  chronic  hysterical  insanity, 
some  cases ;  lactational  insanity,  a  few  cases ;  mania,  acute, 
simple,  and  transitory ;  partial  exaltation  ;  periodical  mania  ; 
podagrous  insanity,  many  cases  ;  pubescent  insanity,  most  cases  ; 
puerperal  mania ;  rheumatic  insanity,  some  cases ;  expansive 
syphilitic  insanity  ;  mania  a  jjotu ;  saturnine  and  mercimal  in- 
sanity, some  cases  ;  uterine  insanity,  nearly  one-third  of  cases  : 
masturbational  insanity,  first  and  third  stages  ;  a  few  cases  of 
rheumatic  insanity. 

III. — Delusion,  hallucination,  fixed  idea,  morhid  imjmlse,  m'  extra- 
ordinary actions. — Choreic  insanity,  most  cases ;  confusional 
insanity,  primary  and  chronic  ;  post-febrile  consecutive  insanity, 
some  cases  ;  delusional  insanity  (monomania,  paranoia) ;  folie  a 
deux ;  folie  du  doute  ;  impulsive  insanity  ;  katatonia,  excited 
stage ;  mania,  delusional ;  melancholia,  delusional,  hypochon- 
driacal, and  religious  ;  moral  insanity  ;  ovarian  insanity  ;  partial 
emotional  aberration ;  phthisical  insanity  ;  somnambulism  pseudo- 
insanity  of  ;  insanity  from  cannabis  indica  ;  traumatic  insanity. 

IV. — Acquired  mental  weakness. — Severe  and  advanced  catalejDtic 
insanity  ;  advanced  consecutive  insanity ;  terminal  dementia ; 
chi  onic  epileptic  insanity  ;  advanced  katatonia  ;  masturbational 
insanity,  fourth  stage  ;  primary  mental  deterioration ;  alcoholic 
dementia ;  advanced  pubescent  insanity ;  puerperal  insanity, 
some  cases  ;  advanced  saturnine  and  mercurial  insanity ;  senile 
insanity ;  depressive  sjqDhilitic  insanity ;  advanced  traumatic 
insanity. 

V. — Acquired  mentcd  weakness  with  dehsions  and  hallucinations. — 
Chronic  mania;  insanity  of  myxoedema ;  delirium  tremens; 
chronic  alcoholic  insanity  ;  insanity  from  absinthe  ;  insanity  from 
opium. 

VI. — Acquired  mental  weakness  with  paresis. — General  paralysis; 
alcoholic  pseudo-general  paralysis  ;  senile  insanity,  some  cases  ; 
severe  delirium  tremens  ;  chronic  alcoholic  insanity. 

VII. — Acquired  mental  vjeakness  ivith  pandysis. — Insanity  from 
coarse  brain  disease  ;  alcoholic  dementia  in  females  ;   syphilitic 


WITH   THEIR   SYNONYMS   AND   SYMPTOMS.  133 

pseudo-general  paralysis  ;  advanced  general  paralysis  ;  traumatic 
insanity  ;  satui'nine  pseudo-general  paralysis  ;  senile  dementia. 

VIII. — Stupor. — Anergic  stupor  ;  melancholic  stupor  ;  general 
paralytic,  epileptic,  and  cataleptic  stupor ;  rheumatic  insanity, 
most  cases  ;  uterine  and  ansemic  insanity,  some  cases  ;  sometimes 
after  acute  mania  ;  some  cases  of  periodical  melancholia  and  of 
melancholy  phase  of  circular  insanity. 

IX. — Delirium  with  unconsciousness. — Acute  delirium  ;  delirium 
of  young  children,  most  cases ;  insanity  of  Bright's  disease ; 
insanity  of  cyanosis  from  Bright's  disease,  cardiac  disease  and 
asthma. 

X. — Congenital  mental  or  moral  tveahness. — Idiocy  ;  imbecilit}^  j 
cretinism  ;  moral  imbecility. 


134 


ETIOLOGY. 


CHAPTEE    IV. 
ETIOLOGY.     ■ 

A.— GENERAL. 

Causes  of  Insanity  in  England  and  Wales  from  1878  to 

1887  Inclusive,  as  shown  by  the  Effort  of  the 

Commissioners  in  Lunacy,  June,  1889. 


Moral. 

Domestic  trouble  (includmg  loss  of  relatives 
and  friends)      ...         

Adverse  circumstances  (including  business 
anxieties  and  iDecuniarj^  difficulties) 

Mental  anxiety  and  "worry"  (not  included 
under  the  above  two  heads)  and  overwork 

Religious  excitement 

Love  affairs  (including  seduction) 

Fright  and  nervous  shock 

Physical. 


Intemperance,  in  drink 

,,  sexual 

Venereal  disease 
Self-abuse  (sexual) ... 

Over-exertion  

Sunstroke 

Accident  or  injury  ... 

Pregnancy     

Parturition  and  the  puerperal  state 

Lactation      ... 

Uterine  and  ovarian  disorders    ... 

Puberty 

Change  of  life 

Fevers 

Privation  and  starvation  ... 

Old  age  

Other  bodily  diseases  or  disorders 

Previous  attacks 

Hereditary  influence  ascertained 

Congenital  defect  ascertained 

Other  ascertained  causes  ... 

Unknown 


Proportion  per  cent,  on 
Total  Number  admitted. 


5-9 


M. 

F. 

4-2 

9-7 

8-2 

3-7 

i  6-6 

5-5 

2-5 

2-9 

•7 

2-5 

•9 

1-9 

19-8 

7-2 

1-0 

•6 

•8 

•2 

2-1 

•2 

•7 

•4 

2-3 

•2 

5-2 

1-0 

1-0 

6-7 

2-2 

2-3 

•6 

•2 

4-0 

•7 

•5 

1-7 

2-1 

3-8 

4-6 

11-1 

10-5 

14-3 

18-9 

19-0 

22-1 

5-1 

3-5 

2-3 

1-0 

21-3 

20-1 

6- 
2-7 
1-6 
1-4 


13-4 

•7 

•5 

1-2 

•5 

1-2 

3-0 

•5 

3-4 

1-1 

1-2 

•4 

2-0 

•6 

1-9 

4-2 

10-8 

16-6 

20-5 

4-3 

1-7 

20-7 


ETIOLOGY.  135 

PREDISPOSING  CAUSES. 

Under  this  head  the  International  Congress  in  1867  included 
hereditary  influence,  pure  consanguinity,  great  difference  of  age 
between  parents,  influence  of  soil  and  of  surroundings ;  convul- 
sions or  emotions  of  the  mother  during  gestation ;  epilepsy  ; 
other  nervous  affections ;  pregnancy ;  lactation ;  menstrual 
period,  critical  age ;  puberty ;  intemperance  (habitual  excess, 
dating  far  back) ;  venereal  excess,  and  onanism. 

Under  this  head  Bucknill  and  Tuke  (p  57,  et  seq.)  include 
heredity ;  constitution,  or  diathesis  ;  consanguineous  marriages 
where  parents  are  both  neurotic  ;  male  sex  (to  a  slight  extent) ; 
age  between  30  and  40,  then  40  and  50,  20  and  30,  50  and  60, 
60  and  70,  70  and  80,  80  and  90,  10  and  20 ;  the  summer  season, 
especially  in  June  (in  France,  at  least) ;  certain  professions  and 
trades  ;  (1st,)  soldiers ;  (2nd,)  merchants,  bankers,  etc. ;  (3rd,) 
unoccupied  proprietors  ;  (4th,)  professional  men,  artists,  scientists, 
etc. ;  (5th,)  innkeepers,  servants,  etc.  ;  (6th,)  carriers,  porters, 
messengers,  etc. ;  (7th,)  agiiculturists,  fishermen,  etc. ;  (8th,) 
mechanics,  etc. ;  (9th,)  butchers,  1>akers,  grocers,  greengrocers, 
etc.  ;  civilisation  pauperism,  celibacy. 

EXCITING   CAUSES. 

Bucknill  and  Tuke  (page  91)  give  as  the  order  of  frequency  : — 

Physical. 
Intemperance. 
Epilepsy — six  per  cent. 

Affections  of  the  head  and  spine — six  per  cent. 
Uterine    disorders,    viz.,    those  of    menstruation,    pregnancy, 
parturition,  lactation — five  per  cent. 
Sexual  vice. 
Fever  and  febrile  diseases  —two  to  three  per  cent. 

Moral. 
Domestic  troubles  and  grief — fourteen  per  cent. 
Religious  anxiety  and  excitement — three  per  cent. 
Disappointed  affections — three  per  cent. 
Fear  and  fright — two  to  three  per  cent. 
Intense  study. 

Political  and  other  excitement  (joy,  etc.). 
Wounded  feelings. 
Or,  without  reference  to  the  division  into  physical  and  moral : — 
Domestic  trouble  and  domestic  grief. 
Intemperance. 
Epilepsy. 
Affections  of  head  and  spine. 


136  EnOLOGY. 

Uterine  disorders. 
Religious  anxiety  and  excitement. 
Disappointed  affections. 
Sexual  vice. 

.  Fever  and  febrile  diseases. 
Fear  and  fright. 
Intense  study. 

Political  and  other  excitement. 
Wounded  feelings. 

Under  the  head  of  "  Exciting  Causes  "  the  International  Con- 
gress of  1867  included  : — 

I.  Physical  Causes. — Artificial  deformities  of  cranium ;  con- 
vulsions of  infancy  and  dentition  ;  cerebral  congestion  (primary, 
not  that  which  arises  in  the  course  of  certain  forms  of  insanity) ; 
organic  affections  of  the  brain  ;  senility  ;  pellagra  ;  anaemia  ; 
constitutional  syphilis  ;  intermittent  fevers  ;  acute  rheumatism  ; 
gout  and  chronic  rheumatism  ;  organic  affections  of  the  heart ; 
pulmonary  phthisis ;  intestinal  Avorms ;  other  acute  diseases  ; 
other  chronic  diseases ;  suppression  of  hsemorrhoidal  flux ; 
menstrual  disorders ;  metastasis ;  alcoholic  drinks ;  abuse  of 
tobacco ;  other  vegetable  poisons  ;  mineral  poisons  (lead,  mercury, 
copper,  etc.) ;  insolation  ;  intense  heat  ;  intense  cold  ;  blows  and 
falls  upon  the  head  ;  other  traumatic  causes. 

II.  Moral  Causes. — Religion  ;  education  ;  loA^e  (love  thwarted, 
jealousy) ;  family  affections ;  fluctuations  of  fortune  ;  domestic 
troubles  ;  pride  ;  disappointed  ambition  ;  fright ;  irritation  ; 
anger  ;  wounded  modesty  ;  political  events  ;  nostalgia  ;  ennui ; 
misanthropy ;  sudden  ]oy  ;  simple  imprisonment ;  solitary  con- 
finement. 

III.  Mixed  Causes. — Excess  of  intellectual  work  ;  prolonged 
vigils  ;  evil  habits  of  libertinism ;  onanism  (sometimes  simply 
predisposing) ;  disorders  of  the  reproductive  system  ;  destitution 
and  want ;  liacl  treatment ;  sudden  change  from  a  life  of  activity 
to  idleness  and  vice  versa ;  loss  of  one  or  more  of  the  senses 
(Bucknill  and  Tuke,  pp.  107-108). 

The  insane  diathesis,  constitution,  or  predisposition  is  generally 
hereditary,  but  it  may  be  acquired  by  the  influence  of  certain 
somatic  and  psychical  ca.uses  ;  amongst  the  former  are  traumatism, 
insolation,  radiant  heat,  syphilis,  alcohol  and  other  narcotics, 
etc.  Amongst  the  latter  are  faulty  educational  systems,  early 
emotional  overstrain,  harsh  treatment,  sensational  reading,  and 
ambitious  rivalry  (Spitzka). 

Batty  Tuke  remarks  ("Brit.  Med.  Journ.,"  May  30,  1891),  that  in 
nearly  90  per  cent,  of  the  cases  insanity  is  traceable  to  eight  great 
classes  of  causes :  (1,)  Idiopathic  morbid  processes ;  (2,)  Traumatic 


ETIOLOGY. 


137 


injury;  (3,)  Ach^entitious  products ;  (4,)  Secondary  effects  of  other 
neuroses ;  (5,)  Concurrent  effects  on  the  brain  of  diseases  of  the 
general  system  ;  (6,)  Toxic  Agents;  (7,)  Concurrent  effects  on  the 
brain  of  evolutional  and  involutional  conditions  ;  (8,)  Heredity. 


B.— SPECIAL. 


Forms  of  Insanity. 


Causes. 


Abdominal  Dis- 
orders, Insanity 
from,  includino 
Sibbald's  Gastro- 
enteric Insan- 
ity. 

Adolescent  Insan- 
ity. 


Anemic  Insanity. 

Bright's  Disease — 
Insanity  of. 

Cataleptic  Insan- 
ity. Causes  of 
Catalepsy. 

Choreic  Insanity. 
Causes  of  Chorea. 


Circular  Insanity. 


Climacteric  Insan- 
ity. 

Coarse  Brain  Di- 
sease,    Insanity 

FROM. 


Irritation  and  catarrh  of  the  gastric  or 
intestinal  mucous  membrane.  Constipa- 
tion. Stricture  or  other  causes  of  disten- 
sion of  the  Adscera.  Epigastric  tumours. 
Catarrh  of  bladder.  Hepatic  derange- 
ment (Sibbald,  "  Quain's  Dictionary "; 
Bucknill  and  Tuke). 

Neuj-otic  heredity,  in  a  very  large  per- 
centage of  cases.  Male  sex.  Mental 
weakness  ;  intellectual  oversti-ain  ;  mas- 
turbation. Age  18-25,  notably  20-25 
(Clouston). 

Starvation  ;  chlorosis  ;  prolonged  indi- 
gestion, or  other  cause  of  anaemia. 

Chronic  Bright's  disease,  ivith  con- 
tracted kidneys  and  enlarged  heart. 

Neurotic  heredity ;  female  sex  ;  jouberty ; 
hysteria ;  epilepsy ;  chronic  cerebral 
disease ;  gastric  and  intestinal  irritation. 
Great  emotional  disturbance  (Eoss). 

Neurotic  heredity;  rheumatic  diathesis: 
rheumatism ;  early  life ;  female  sex  ; 
onanism ;  pregnancy ;  menstrual  dis- 
orders ;  chlorosis ;  emotional  disturl)ances 
(fright,  sorrow,  and  discontent)  (Eoss). 

Neurotic  heredity  ;  youth  ;  education  ; 
ancient  lineage;  diurnal,  menstrual, 
sexual,  and  seasonal  periodicities  of  the 
brain  (Clouston). 

Heredity,  female  sex.  Age,  40-50  in 
females  ;  55-65  in  males  (Clouston). 

Cardiac  disease ;  arterial  atheroma ; 
cerebral  hsemorrhage ;  cerebral  softening 
from  thrombosis  or  embolism.  Cerebral 
tumour.  Cereliral  atrophy.  Chronic 
cerebral  degeneration. 


138 


ETIOLOGY. 


Forms  of  Insanity. 


Causes. 


CONFUSIONAL  IN- 
SANITY, Primary 
OR  Acute. 

CONFUSIONAL  IN- 
SANITY,  Chronic. 

Consecutive  In- 
sanity. 


Cyanosis  from 
Bronchitis,  Car- 
diac Diseases, 
AND  Asthma,  In- 
sanity OF 

Delirium,  Acute. 


Delusional  Insan- 
ity. 


Dementia,  Termin- 
al. 

(1,)  Apathetic. 
(2,)  Agitated. 


Deprivation  of  the 
Senses,  Insanity 
from. 


Cei'ebral  exhaustion  ;  emotional  shock  ; 
cerebral  overstrain  ;  exhausting  diseases  ; 
excesses  (Spitzka). 

Mania ;  melancholia  ;  primary  conf  u- 
sional  insanity  (Spitzka). 

Small-pox ;  typhus,  typhoid,  intei'- 
mittent  fever  ;  measles  ;  erysipelas.  The 
acute  anginas ;  cholera ;  acute  rheu- 
matism. 

Advanced  age  ;  hereditarily  weak  brain 
(Clouston). 


More  common  in  females  than  males. 
Often  hereditary  predisposition.  Insola- 
tion ;  privation ;  physical  exhaustion ; 
intellectual  exhaustion  or  emotional 
strain  ;  alcoholic  excesses  ;  business  crises. 
Puerperal  state  (Spitzka,  Bra). 

Neurotic  heredity  ;  congenital,  cerebral, 
or  bodily  malformations ;  other  somatic 
anomalies ;  exaggerated  physiological  men- 
tal states  (pride,  suspicion,  sexual  emo- 
tions, etc.)  passing  into  delusions.  Hal- 
lucinations slowly  leading  up  to  the  deve- 
lopment of  fixed  delusions.  The  delusion 
or  delusions  may  simply  arise  out  of  some 
false  idea,  accepted  without  discussion. 
Typhus  fever  ;  head  injuries  ;  alcoholism  ; 
dreams ;  great  emotional  strain ;  mono- 
tonous ideation  (Bra,  Spitzka,  Clouston, 
Savage). 

(1,)  Anergic  stupor;  stuporous  melan- 
cholia ;  violent  outbreaks  of  maniacal 
furor. 

(2,)  Chronic  mania;  agitated  melancholia 
(Spitzka). 

The  loss  of  one  or  more  of  the  special 
senses,  sight,  hearing,  etc.  (Clouston). 


ETIOLOGY. 


139 


Forms  of  Insanity. 


Causes. 


Deterioration,  Pri- 
]MARY  Mental. 

Diabetic  Insanity. 

Epileptic  Insanity. 

Exophthalmic 

Goitre,  Insaniit 

WITH. 

FoLiE  A  Deux. 

FOLIE   DU   DOUTE. 


FOLIE  Kaisonnante. 


General  Paralysis 
OF  THE  Insane. 


Excitement ;  intellectual  exhaustion  • 
emotional  strain ;  continuous  mental 
worry  (Spitzka). 

Diabetes  Mellitus. 

Epilepsy. 

Graves'  disease. 


See  Chap.  III. 

Neuropathic  or  insane  heredity  in  most 
cases.  Age  of  puberty  ;  female  sex  ;  high 
social  position  ;  inveterate  onanism  ;  erup- 
tive fevers  ;  fright ;  emotional  excitement ; 
excessive  intellectual  work.    Neurasthenia, 

C[.V. 

Heredity  ;  neurasthenia  ;  hysteria  ; 
uterine  affections,  especially  infarcts  and 
displacements  (Krafft-Ebing). 

Age  between  20  and  60,  especially 
35  to  45  ;  male  sex ;  mental  overwork, 
especially  attempts  to  do  Avork  above  the 
capacity  ;  deception  ;  ambition  ;  jealousy  ; 
disappointment  and  vexation ;  sexual 
excess  ;  alcoholic  excess  ;  syphilis ;  erysi- 
pelas of  the  scalp ;  insolation ;  trau- 
matisms, especially  falls  on  the  head. 

Combination  of  intellectual  over-work, 
emotional  strain,  and  alcoholic  excess 
most  potent.  Mickle  gives  as  predis- 
ponents :  male  sex  ;  age  30-50  ;  energetic 
mental  life  with  ardent  imagination ; 
neurotic  heredity  ;  married  life  ;  military 
and  naval  life  ;  exposure  to  great  heat  or 
alternate  heat  and  cold ;  prostitution ; 
professional  and  literary  occupations,  as 
they  entail  strain,  worr}^,  and  overwork ; 
ambitious  projects  ;  prolonged  and  violent 
or  sudden  and  frequent  feeling  or  passion, 
as  worry,  indignation,  rage,  or  lust, 
chagrins ;  forced  erethism  of  the  intellec- 
tual faculties ;  intellectual  overwork, 
especially    if    sustained    by    stimulants ; 


140 


ETIOLOGY. 


Forms  of  Insanity. 


Causes. 


Hysterical 

SANITY. 


IN- 


Ctestational  Insan- 
ity. 


cessation  of   discharges  ;    cranial  injuries  ; 
urban  life. 

As  excitants,  he  gives  :  (1,)  Alcoholic 
excess ;  (2,)  Excessive  and  prolonged 
intellectual  labour  with  undue  emotional 
tension ;  (3,)  Protracted  painful  emo- 
tional strain ;  (4,)  Exhausting  heavy 
physical  labour ;  (5,)  Sexual  excess. 
Each  of  the  last  four  being  in  many  cases 
associated  with  undue  alcoholic  stimulation. 

Savage  ("Brit.  Med.  Journ.,"May  4, 1890) 
says  general  paralysis  is  a  degeneration 
"most  commonly  met  with  in  middle-aged 
married  men,  inhabitants  of  cities,  flesh 
eaters,  and  drinkers  of  alcohol."  It 
frequently  follows  syphilis,  especially  if 
the  disease  has  affected  the  higher  nervous 
organs  or  their  envelopes.  Head  injuries 
not  uncommonly  originate  it,  as  do  causes 
of  nerve  tissue  change,  such  as  lead.  "  It 
is  not  common  among  the  congenitally 
deficient,  or  among  ej)ileptics." 

In  addition  to  several  of  the  causes 
already  mentioned,  Voisin  ("Traite  de  la 
Paralysie  G6nerale  des  Ali6n6s,"  page  309 
et  scq.)  gives  :  Bad  moi^al  hygiene ;  political 
events ;  intestine  dissensions  ;  clomestic 
troubles ;  abuse  of  tobacco ;  dietetic 
abuses  ;  pellagra ;  diabetes  ;  epilepsy  ; 
simple  insanity. 

Generally  after  third,  most  frequently 
after  sixth  month  of  pregnancy  (Cloiis-. 
ton).  Formed  one  per  cent,  of  cases  in 
Royal  Edinburgh  Asylum  during  nine 
years. 

Of  hysteria,  Ross  ("Diseases  of  the 
Nervous  System,"  p.  865)  gives  neurotic 
heredity  ;  female  sex  ;  puberty  ;  depress- 
ing passions,  as  fear,  anxiety,  jealousy, 
and  remorse  ;  exhaustion  from  overwork 
combined  with  anxiety  ;  uterine  derange- 
ments, structural  or  functional ;  imitation. 


ETIOLOGY. 


141 


Forms  of  Insanity. 


Causes. 


(1,)  Idiocy  and  Im^ 
becility. 


(2,)  Cretinism. 


Impulsive 

ITY. 


Insan- 


Katatonic     Insan- 
ity,    OR     Kata- 

TONIA. 

Lactational  Insan- 
ity. 
Mania. 


Masturbational 

Insanity. 
Melancholia. 


Neurotic  heredity ;  advanced  age  of 
parents ;  consanguinity,  especially  when 
both  parents  are  scrofulous  or  rachitic  ; 
acute  alcoholism  at  time  of  conception; 
syphilis ;  diseases  and  emotions  of  the 
mother  during  pregnancy ;  difficult  labour  ; 
maladroit  obstetrical  manipulations  ;  acci- 
dental traumatisms ;  too  forcilile  com- 
pression of  the  child's  head ;  eruptive 
fevers  in  the  child  (Bra,  p.  210). 

Marriage  of  inhabitants  of  infected  dis- 
tricts ;  consanguineous  marriages ;  ad- 
vanced age  and  bad  constitution  of 
parents  ;  defective  alimentation  ;  misery  ; 
dirt ;  overcrowding  ;  narrow  valleys  sur- 
rounded l)y  high  mountains  ;  snow  water  ; 
water  of  chalky  districts,  charged  with 
carbonate  or  sulphate  of  lime  ;  water  con- 
taining too  much  magnesia,  aluminum,  or 
too  little  oxygen  or  iodine ;  miasmata. 
Although  essentially  endemic,  it  may  be 
acquired  by  children  sent  to  live  in  the 
infected  districts  (Bra,  p.  223). 

Insane  or  neurotic  heredity ;  critical 
periods  of  life  ;  menstruation,  pregnancy, 
and  puerperium  ;  acute  moral  sufFeiing  ; 
overwork  ;  sexual  excess  ;  alcoholic 
excesses  on  the  part  of  patient  or  his 
parents. 

Masturbatory  excesses ;  disappointment 
in  love  (Spitzka,  p.  150). 

Lactation  in  weak,  overworked,  and 
ill-fed  women. 

Heredity,  similar  or  dissimilar ;  mental 
anxiety ;  adverse  circumstances ;  over- 
work ;  alcoholic  excess  ;  sexual  excess. 

Neurotic  heredity ;  nervous  tempera- 
ment ;  masturbation. 

Heredity ;  puberty  and  the  climacteric  ; 
female  sex ;  certain  occupations,  viz., 
those  of  clergymen,  artists,  soldiers,  doc- 


142 


ETIOLOGY. 


Forms  of  Insanity. 


Causes. 


Metastatic    Insan- 
ity. 

Moral  Insanity. 


Myxcedema,  Insan- 
ity OF. 

Neurasthenic  In- 
sanity. 


Ovarian    or     Old 
Maid's  Insanity. 


tors,  lawyers,  journalists,  actors,  politi 
cians ;  intellectual  overwork ;  worry ; 
adverse  circumstances  ;  faulty  education  ; 
the  puerperal  state ;  masturbation ;  con- 
sanguineous marriages  ;  civilisation  ;  poli- 
tical, religious,  or  social  commotions ; 
solitary  confinement ;  any  debilitating, 
causes. 

Metastasis  ;  rheumatism,  chronic  ulcer, 
erysipelas,  and  other  diseases ;  neurotic 
heredity  and  constitution. 

Any  ordinary  cause  of  insanity.     Apo- 
plectic    or    epileptic   seizures ;    alcoholic 
j  excess ;     an   attack   of    acute    mania    or 
I  melancholia  (Blandford,  "  Quain's  Diction- 
ary,"_  p.  727). 

Etiology  of  myxcedema  (Ord,  "Quain's 
Diet.,"  p.  1015);  female  sex;  adult  age. 

Of  neurasthenia  cerebralis,  mental  over- 
work, especially  in  conjunction  with 
emotional  excitement.  Of  spinal  neuras- 
thenia, bodily  overwork,  severe  illnesses, 
puerperia,  sexual  excesses,  emotional 
strain.  Of  neurasthenia  cordis  (visceral 
neurasthenia),  in  asthenic  individuals, 
emotional  strain,  too  warm  baths,  excessive 
tobacco  smoking.  Of  sexual  neurasthenia, 
masturbation,  sexual  excesses,  psychical 
onanism,  gleet ;  in  addition  in  women, 
puberty  ;  the  climacteric  ;  incomplete  or 
interrupted  coitus ;  utei^ne  tumours, 
infarcts,  displacements,  and  erosions.  The 
neurasthenic  degenerative  psychosis  with 
fixed  ideas  is  founded  on  a  basis  of  neu- 
rasthenia which  is  sometimes,  though 
rarely,  acquired  through  mental  over- 
exertion, emotional  strain,  exhausting 
diseases,  parturitions  in  quick  succession, 
lactation,  sexual  excess,  onanism ;  it  is 
then  curable  (Kraff"t-Ebing). 

Age  shortly  before  the  climacteric. 


ETIOLOGY. 


143 


Forms  of  Insanity. 


Causes. 


oxaluria  and 
Phosphaturia, 
Insanity  of. 

Paralysis  Agitans, 
Insanity  of. 


Partial  Emotional 
Aberration. 

Partial      Exalta- 
tion,  or  Ameno- 

MANIA. 

Pellagrous  Insan- 
ity. 


Periodical  Insan- 
ity. 

Phthisical  Insan- 
ity. 

Podagrous  or 
Gouty  Insanity. 

Post-Connubial  In- 
sanity. 

Pubescent  Insan- 
ity. 

Puerperal  Insan- 
ity. 


Middle  age ;  oxalic  diathesis ;  better 
class  of  society  ;  too  free  indulgence  in 
eating,  especially  in  eating  sweets. 

Long-continued  paralysis  agitans  (Bra); 
paralysis  agitans,  etiology  of;  advanced 
life ;  male  sex ;  exposure  to  cold  and 
damp ;  great  emotional  disturbance ; 
wounds  and  other  injuries. 

Neurasthenia  (see  above). 

Neurotic  heredity ;  exaggerated  phy- 
siological emotions,  pride,  vanity,  ambi- 
tion, etc.  ;  epidemic  religious  influences. 

Pellagra  frequently  occurs  in  Italy.  Of 
Pellagra  ;  heredity  ;  j)overty  ;  insufficient 
and  improjDcr  food  and  clothing  ;  malaria  ; 
unwholesome  maize;  sporisorium  maydis. 
Exciting  cause,  sun's  rays,  especially 
"vernal  insolation"  (Erasmus  \Yilson, 
"Quain's  Dictionary,"  p.  1103). 

Neiu'otic  heredity  ;  cranial  injiuries  ; 
alcoholic  excess  ;  menstruation  ;  puberty  ; 
climacteric. 

Latent  phthisis  (Sibbald).  Insane  here- 
dity 7  per  cent,  more  than  in  the  insane 
generally  (Clouston). 

Gout,  especially  where  there  is  strong- 
gouty  heredity  (Clouston). 

Mental  excitement  and  sexual  excess. 

Neurotic  Iteredity  ahuays.  Irregularity 
in  coming  on  of  reproductive  or  menstrual 
function  (Clouston,  p.  525). 

Direct  heredity ;  commonly  old  primi- 
parae ;  prolonged  previous  suckling ; 
rapidly  recurring  pregnancies  ;  twins  ; 
alcoholic  excess  during  pregnancy ;  Ul- 
ceration or  abscess  of  breast  ;  eclampsia  ; 
pyaemia  ;  chloroform. 

Grief ;  worry  ;  anxiety ;  seduction ; 
birth    of   natiu-al  children ;   desertion   or 


144 


ETIOLOGY. 


Forms  of  Insanity. 


Causes. 


Rheumatic    Insan- 
ity. 


Senile  Insanity. 


Somnambulism, 
Pseudo-Insanity 
of. 

Stupor,  Anergic 
(Acute  Demen- 
tia; Acute  Pri- 
mary Dementia  ; 
Stuporous  In- 
sanity). 


Syphilitic 

ITY. 


Insan- 


Toxic  Insanity. 


death  of  husband  ;  loss  of  child  (Savage, 
p.  372). 

Male  sex  ;  age  20-40  ;  heredity  ;  mental 
overwork ;  alcoholism ;  melancholy  or 
nervous  disposition.  Hysteria,  epilepsy, 
alcoholism,  plumbism  in  the  parents 
predispose  ;  metastasis  ;  hyperpyrexia  ; 
cardiopathy  ;  therapeutic  agents  (Bra, 
p.  99.) 

Insane  heredity ;  vascular  diseases ; 
previous  mental  overwork  or  disturbance 
of  brain  function.  Generally  over  60 
years  of  age  (Clouston,  p.  566). 

Neurotic  heredity ;  nervous  tempera- 
ment (Clouston,  p.  608).  Disorders  of 
digestion. 

Adolescence  ;  masturbation  ;  excessive 
sexual  intercourse,  with  or  without  mental 
and  emotional  exaltation ;  starvation ; 
exhausting  discharges  ;  mental  overwork 
during  adolescence ;  mental  and  moral 
shocks ;  profuse  haemorrhage ;  alcoholic  ex- 
cess (Spitzka,  p.  159  ;  Clouston,  p.  307). 

Syphilis  ;  neurotic  predisposition,  most 
commonly  hereditary ;  traumatism ;  mental 
fatigue ;  fright.  Excesses  may  act  as 
determining  causes.  S3^mptoms  generally 
appear  between  the  third  and  the  tenth 
year  of  the  disease,  but  may  develop  as 
early  as  the  end  of  the  secondary  or 
beginning  of  the  tertiary  stage,  or  may 
be  postponed  for  30  years  (Bra,  p.  105). 

Cerebral  symptoms  may  appear  in  a 
case  of  syphilis  of  any  degree  of  severity, 
treated  or  not  treated,  and  are  more  liable 
to  appear  in  cases  Avhere  the  symptoms 
have  been  mild  or  only  moderately  severe 
(Fournier). 

Neurotic  heredity  ;  alcohol ;  absinthe  ; 
opium  or  its  alkaloids  ;  chloral ;  cannabis 
indica  ;  lead  ;  mercury,  etc.  (See  "  Toxic 
Insanity,"  Chap.  III.) 


ETIOLOGY. 


145 


Forms  of  Insanity. 


Causes. 


Traumatic 

ITY. 


Insan- 


Uterine  or  Amen- 
orrhceal  insan- 
ITY. 

Young  Children, 
Delirium  of 


Blows  on  head  ;  falls  on  head  ;  other 
traumatic  injuries  to  brain ;  sunstroke ; 
radiant  heat  (Clouston,  p.  414;  Spitzka, 
p.  371). 

Disordered  or  suspended  menstruation. 


Bodily  ailments  ;  pyrexia. 


No  two  cases  of  insanity  are  exactly  alike,  and  when  en- 
deavouring to  discover  the  cause,  or  more  correctly  speaking,  the 
causes  (as  there  are  generally  several)  of  any  given  case,  the 
past  history  of  the  patient  and  his  immediate  relatives  (the 
anamnesia  or  anamnestic  symptoms  of  the  case)  should,  if 
possible,  be  ascertained.  In  the  patient's  history  care  should  be 
taken  to  discriminate  between  causes  and  symptoms  or  pro- 
dromata.  When  enquiring  about  the  relatives,  it  is  best  to  ask 
what  diseases  they  have  suffered  from  or  died  of,  and  not  to  put 
the  direct  question  whether  they  have  ever  suffered  from  insanity 
or  any  other  nervous  disease,  or  any  chronic  intoxication,  or 
phthisis,  etc.  Although  statistics  only  show  heredity  in  about 
20  per  cent,  of  total  admissions,  50  per  cent,  would  be  nearer  the 
truth.  Structure  and  environment  bear  an  inverse  ratio  to  each 
other  in  the  causation  of  the  insanities  as  of  other  diseases 
(Campbell).  Given  a  perfectly  healthy  cerebral  structure,  only 
the  most  powerful  causes  will  produce  insanity,  if  it  can  be 
produced  at  all.  Given,  on  the  other  hand,  strong  hereditary 
tendency  with  somatic  stigmata  (these  are  often  accompanied  by 
cerebral  structural  anomalies),  as  in  some  of  the  psychical 
degenerative  forms,  then  a  very  slight  disturbance  will  be 
sufficient  to  upset  the  unstable  mental  equilibrium  and  complete 
the  causation. 


10 


146  DIAGNOSIS, 


CHAPTEE    V. 

DIAGNOSIS. 

A.— DIAGNOSIS    OF   INSANITY  FROM   OTHFB 
CONDITIONS. 

Of  insanity  from  (1,)  Eccentricity  ;  (2,)  Feigned  insanity;  (3,) 
The  delirium  of  fevers  and  inflammations;  (4,)  Intoxication, 
alcoholic  or  other  ;    (5,)   Cerebral  meningitis  ;   and  (6)  Aphasia. 

I. — Eccentricity. 

In  mere  eccentricity  the  intellectual  faculties  are  not  perverted, 
and,  ■with  the  exception  of  the  judgment,  are  not  even  defective. 
In  one  form  of  eccentricity  the  judgment  is  strong  and  there  is 
an  excess  of  indiAiduality,  with  great  independence  of  thought 
and  action.  In  another  or  weak  form  of  eccentricity  (often 
premonitory  to  or  a  sequel  of  insanity),  "  The  practical  judgment 
is  invariably  weak  ;  the  character  is  marked  by  obstinacy  or 
fickleness  ;  unaccountable  states  of  emotion  often  present  them- 
selves, but  they  are  remarkable  for  their  strangeness  rather  than 
their  force.  The  perverted  emotions  of  the  eccentric  man  are 
feeble  in  comparison  with  those  of  the  Imiatic,  and  it  is  seldom 
that  they  residt  in  offences  against  the  law.  The  propensities  of 
the  eccentric  man  are  normal,  and  his  countenance,  demeanour, 
and  state  of  muscular  actiAdty  are  devoid  of  the  signs  of  insanity " 
(Bucknill  and  Tuke,  p.  444).  The  eccentric  man  of  the  latter 
type  is  influenced  by  the  love  of  applause  and  the  desire  to 
attract  attention,  and  his  conduct  is  ill-regulated,  vacillating,  and 
capricious,  varying  ^A'ith  the  emotion  of  the  moment. 

II. — Feigned  Insanity. 

(1,)  There  is  always  a  motive  for  feigning  insanity,  u.sually  to 
escape  punishment,  often  capital ;  but  it  may  be  to  render  some 
contract  void  ;  to  obtain  admission  into  an  asylum,  or  to  be 
enabled  to  remain  in  one  ;  to  escape  from  or  shorten  the  term  of 
military  service. 

(2,)  There  is  no  history  of  insanity  pre^dous  to  the  commission 
of  the  crime. 

(3,)  The  simulator  always  over-acts  his  part,  especially  if  mania 
is  chosen. 

(4,)  Acts  are  committed  which  are  incompatible  with  the  form 
of  insanity  assumed,  e.g.,  a  melancholic  eating  filth,  etc. 


DIAGNOSIS,  147 

(5,)  There  is  total  inability  to  maintain  motor  excitement  and 
loquacity  for  hours  and  days  together  without  fatigue. 

(6,)  Inability  to  do  Avithout  sleep. 

(7,)  The  simulator  alters  his  demeanour  and  conduct  when  he 
thinks  he  is  unobserved. 

(8,)  The  emotional  state  belonging  to  the  form  of  insanity 
assumed  is  not  (in  some  cases  cannot  be)  correctly  imitated. 

(9,)  When  dementia  is  assumed  the  facial  exj)ression  does  not 
tally. 

(10,)  The  simulator  adopts  suggestions  thrown  out  in  his 
hearing. 

(11,)  There  is  a  pretended  total  loss  of  memory,  though  this 
occurs  in  but  few  forms  of  real  insanity. 

(12,)  The  simulator  will  sometimes  say  that  he  is  suffering 
from  "delusions,"  "hallucinations,"  "mania,"  "monomania,"  etc. 
An  insane  person  never  speaks  in  this  way. 

(13,)  A  dose  of  opium  will  act  much  more  powerfully  on  the 
simulator  than  on  the  real  lunatic. 

(14,)  Certain  objective  symptoms  are  absent,  e.g.,  frequent 
pulse,  furred  tongue,  flushed  or  pallid  countenance,  injected 
conjunctivae. 

An  insane  person  commits  a  crime  without  a  motive,  or  with  a 
trivial  or  outlandish  motive.  There  is  frequently  no  attempt  at 
concealment :  sometimes  even  boastfulness  concerning  the  crime. 
Very  often  there  is  a  history  of  insane  or  neurotic  heredity, 
and  of  conversation  and  conduct  indicating  the  existence  of 
mental  aberration  before  the  commission  of  the  crime. 

III. — The  Delirium  of  Fevers  and  Inflajvimations, 
(Especially  Typhus  and  Pneumonia). 

Fevers  and  inflammations  may  complicate  insanity,  and  it  may 
be  consecutive  to  them.  In  the  absence  of  the  rash  and  the 
physical  and  other  symptoms,  sputum,  pain,  cough,  etc.,  the 
elevated  temperature  distinguishes  febrile  and  inflammatory  deli- 
rium from  all  forms  of  insanity  except  pyretic  delirium  tremens  ; 
acute  rheumatic  insanity ;  some  cases  of  puerperal  insanity  ;  the 
congestive  phases  of  general  paralysis ;  acute  delirium  (acute 
delirious  mania). 

(1,)  Pyretic  delirium  tremens  is  distinguished  by  the  character 
of  the  hallucinations  (painful,  mobile,  and  nocturnal) ;  by  the 
tremor  ;  by  the  history  of  alcoholic  excess. 

(2,)  Acute  rheumatic  insanity  generally  commences  during  an 
attack  of  acute  rheumatism,  most  frequently  from  the  fifth  to  the 
twentieth  day. 


148  DIAGNOSIS. 

(3,)  Puerperal  insanity  is  known  by  the  conditions  under 
which  it  occurs,  by  the  noisiness,  sleeplessness,  destructiveness, 
dirtiness,  jocularity,  and  erotic  tendency ;  by  the  dislike  of  child, 
husband,  and  other  relations ;  by  the  tendency  to  commit  homi- 
cide and  suicide  ;  by  the  diminished  or  suppressed  lacteal  flow  ; 
by  the  suppressecl,  or  altered  and  offensive,  lochial  discharge ;  by 
the  enlarged,  perhaps  tender,  uterus,  and  the  patent  rigid,  irre- 
gular OS,  if  the  circumstance  of  parturition  is  concealed  from  the 
exammer. 

(4,)  The  congestive  phases  of  general  paralysis  are  known  by 
the  previous  history  of  the  patient ;  by  the  somatic  signs  (lingual, 
labial,  and  facial  tremor,  pupillary  inequality,  cutaneous 
anaesthesia,  etc.),  and  by  the  grandiose  delusions. 

(5,)  Acute  delirium  (acute  delirious  mania).  The  prevalence 
of  pneumonia  and  the  presence  of  an  epidemic  of  typhus  or  other 
fevers  must  be  taken  into  account.  The  delirium  of  typhus  is 
generally  low  and  muttering,  and  the  strength  is  prostrated  from 
the  first.  (Typhoid,  as  a  rule,  develops  slowly.)  After  a  few 
days,  in  the  absence  of  all  physical  signs,  or  of  characteristic 
expectoration,  or  of  an  eruption,  or  of  diarrhoea,  headache,  or 
vomiting,  acute  delirium  may  be  diagnosed. 

The  temperature  may  rise  in  some  cases  of  lactational  insanity, 
or  severe  periodical  mania,  but  it  rarely  exceeds  100°. 

It  should  be  borne  in  mind  that  insanity  may  complicate  fevers 
or  inflammation  {e.g.,  complicating  delirium  tremens,  febrile  con- 
secutive insanit)^),  and  that  fevers  and  inflammations  may  com- 
plicate insanity. 

IV. — Alcoholic  or  other  Intoxication. 

This  is  distinguished  by  its  transitory  nature,  generally  ending 
in  sleep  after  a  few  hours.  In  the  case  of  alcohol,  there  is  the 
smell,  vomiting,  and  the  presence  of  alcohol  in  the  gastric 
contents,  obtained  hy  means  of  an  emetic  or  the  stomach-pump 
if  vomiting  is  absent ;  in  ojDium  or  morphia  intoxication  there 
are  the  strongly-contracted  pupils ;  in  belladonna,  the  fixed 
mdely-dilated  pupils  ;  in  Indian  hemp,  the  dreamy -delusional 
state  and  hallucinations  of  an  agreeable  nature.  Early  insanity 
may  be  complicated  by  any  of  these  intoxications. 

V. — Cerebral  Meningitis. 

This  is  distinguished  by  the  acute  headache,  aggravated  at 
intervals  ;  the  persistent  vomiting,  especially  immediately  after 
taking  food  ;  the  intolerance  of  light  and  sound ;  the  contracted 
pupils  ;  the  hard  pulse. 


DIAGNOSIS.  149 

VI.^ — Aphasia. 

Aphasia  is  generally  accompanied  by  paralysis,  which  is 
usually  confined  to  the  right  arm  and  the  right  side  of  the  face  ; 
the  patient  understands  what  is  said  to  him  (with  an  exception 
to  be  mentioned  afterwards),  and  he  is  able  to  reply  by  gestures, 
or  (unless  he  is  agraphic)  in  writing  ;  when  he  does  not  under- 
stand what  is  said  to  him  (word-deafness)  he  understands  ^^iting, 
unless  he  is  word-blind,  and  then  he  understands  gestures,  and 
reacts  in  a  sane  manner. 

In  amnesic  aphasia  the  patient  knows  when  he  has  miscalled 
any  object,  and  immediately  says  "  yes,"  with  a  pleased  expression, 
on  the  correct  name  being  mentioned,  and  he  repeats  the  name, 
although  c[uite  unable  to  recall  it,  when  shown  the  object  a  few 
minutes  afterwards.  An  insane  female  patient  in  Norfolk  Asylum, 
in  1873,  afforded  a  typical  instance  of  this  form  of  aphasia. 

In  all  forms  of  mere  aphasia  the  judgment  is  sound  and  the 
actions  are  well  regulated.  Aphasia  may,  however,  complicate 
insanity,  and  the  latter  may  supervene  on  the  former. 

It  should  be  stated  here  that  Clouston  says  he  has  never 
observed  complete  aphasia  along  with  perfect  mental  sanity,  and 
he  is  inclined  to  believe  that  the  two  are  incompatible.  Max 
Miiller  ("Science  of  Thought")  adduces  strong  arguments  in 
favour  of  his  view  that  thought  is  impossible  without  language, 
or  language  without  thought,  that  thought  is  impossible  Avithout 
words  or  the  signs  replacing  them,  that,  in  fact,  language  is 
thought.  Darwin  ("The  Descent  of  Man,"  p.  89)  referring  to 
this  aphorism  says,  "What  a  strange  definition  must  here  be 
given  to  the  Avorcl  thought !  "  However,  he  admits  {op.  cit.,  p.  88) 
that  a  complex  train  of  thought  absolutehj  requires  words,  as  long 
calculations  do  figiires  or  letters  ;  and  that  an  ordinary  train  of 
thought  almost  requires,  or  is  greatly  facilitated  l)y  words.  Ireland 
("  The  Blot  Upon  the  Brain,"  p.  272)  says,  "  Speech  is,  if  not  an 
indispensable  method  of  arriving  at  any  high  mental  endowment, 
at  least  too  direct  and  obvious  a  one  ever  to  be  dispensed  with." 

In  acquired  insanity  there  is  always  an  alteration  in  the  dis- 
position, demeanour,  habits,  and  conduct  of  the  individual 
affected.  This  should  be  minutely  inquired  into.  There  is  very 
frequently  a  history  of  heredity,  sometimes  of  intemperance, 
cranial  injuries,  masturbation,  or  sexual  excesses.  There  may  be 
a  more  immediate  history  of  overwork,  domestic  troubles, 
business  anxieties,  adversity,  disappointments,  injuries,  illnesses, 
etc.  Age  and  sex  should  be  taken  into  account.  As  to  the 
symptoms,  the  patient  may  evince  emotional  exaltation  or  de- 
pression ;  extreme  loquacity,  or  reticence  amounting  to  absolute 


150  DIAGNOSIS. 

mutism  ;  loss  of  power  of  attention  ;  loss  of  memory  ;  loss  of 
power  of  calculation ;  diminished  will  power  ;  weakened  judg- 
ment ;  morbid  or  exaggerated  jDhysiological  impulses  ;  partial  or 
complete  loss  of  consciousness;  stupor  ;  illusions  ;  hallucinations: 
delusions. 

Method  of  Examining  a  Patient. 

Having  learnt  as  much  as  possible  (including  the  hereditary 
and  personal  history  or  anamnesia)  of  the  patient  from  the 
relatives  or  friends,  or,  if  necessary,  from  his  or  her  acquaintances 
and  neighbours,  the  medical  man  should  be  introduced  to  him  or 
her  as  a  doctor,  and  not,  under  any  circumstances,  as  anything 
else.  The  patient  can  be  examined  physically,  and  whilst  inves- 
tigating the  state  of  the  tongue,  pulse,  temperature,  bowels,  urine, 
appetite,  cardiac  sounds,  pulmonary  sounds,  and  inquiring  about 
pain,  sleep,  etc.,  etc.,  the  doctor  can  generally  form  some 
idea  as  to  the  patient's  temper,  memory,  and  emotional  state 
(simple  melancholia — acute  mania),  and  sometimes  as  to  his 
delusions  (in  hypochondriacal  melancholia,  general  paralysis, 
delusional  mania,  delusional  melancholia,  acute  mania,  puerperal 
insanity,  chronic  mania,  dementia  ■with  delusions).  At  the  same 
time  the  dress,  attitude,  actions,  demeanour,  gestures,  action  of 
facial  and  oral  muscles,  facial  expression,  and  ajDpearance  of  eyes 
may  be  noticed,  and  when  the  patient  is  absolute^  mute,  or 
when  he  refuses  to  speak  to  the  doctor,  these  are  the  j)rincipal 
and  often  the  only  symptoms  to  constitute  the  statutory  "  facts 
observed  by  myself  "  (anergic  stupor,  stuporous  melancholia,  and 
some  cases  of  delusional  insanity  ;  see  "  Differential  Diagnosis," 
post).  In  these  mute  cases  food  is  generally  refused,  or  only 
swallowed  if  put  well  back  into  the  mouth.  This  can  be  verified 
by  the  medical  practitioner.  Inquire  as  to  habits,  whether 
"  wet,"  or  "  dirty,"  or  both.  Inquire  as  to  sleej),  rest  at  night, 
impulsive  violence  in  Avord  or  deed. 

Where  the  patient  converses,  or  even  answers  questions,  and 
it  has  been  found  in  the  preliminary  physical  examination  that 
his  temper  is  facile  and  his  intellect  more  or  less  enfeebled,  the 
extent  of  this  enfeeblement  may  be  ascertained  by  some  simple 
questions,  requiring  the  patient  to  name  the  year,  the  season  of 
the  year,  the  month,  the  day  of  the  Aveek ;  asking  him 
where  he  is  and  hoAv  long  he  has  been  in  such  jjlace,  his  age,  the 
year  in  Avhich  he  was  boi^n,  his  occupation,  and  how  long  he  has 
been  so  employed,  the  number  and  names  of  his  or  her  children, 
brothers  and  sisters,  etc.,  etc.  "Where  from  these  questions  it  is 
inferred  that  the  poAver  of  calculation  is  Aveak,  this  may  be  still 
more  accurately  tested  l^y  a  few  easA^  arithmetical  questions. 


DIAGNOSIS.  151 

The  defective  memory  and  the  weakness  of  the  power  of  cal- 
culation suggest  some  form  of  dementia,  idiocy  or  imbecility, 
or  general  paralysis.  Therefore,  where  these  mental  symp- 
toms are  present,  look  carefully  for  somatic  stigmata  and 
symptoms  ;  microcephalus,  hydrocephalus,  vaulted  or  cleft  palate, 
decayed  teeth  (idiocy  and  imbecility) ;  hemiplegia  contractures, 
aphasia,  hemi-ansesthesia  (organic  dementia) ;  tremulous,  stam- 
mering, or  stuttering  speech ;  lingual,  labial,  and  facial 
fibrillary  tremor ;  slight  paralysis ;  cutaneous  anaesthesia ; 
tripping-stumbling  gait ;  awkwardness  in  turning  (general 
paralysis). 

When  the  patient's  memory  is  good,  propounding  simple 
questions,  such  as  those  indicated,  is  liable  to  cause  irrita- 
tion and  prevent  the  delusions  being  ascertained  at  first 
hand. 

In  such  cases  the  conversation  may  be  carefully  led  from  the 
patient's  physical  ailments  to  such  topics  as  his  friends  or 
relations,  his  enemies,  his  occupation  and  employer,  his  social 
position,  his  past  life,  his  worldly  prospects,  the  future  state. 
In  this  way  most  delusions  may  be  brought  out,  and  even 
cunning  chronic  patients  will  generally,  by  their  manner  of 
answering  questions,  betray  the  fact  that  they  still  retain  their 
delusions.  Hallucinations  should  be  sought  for.  Their  presence 
will  sometimes  be  betrayed  by  the  facial  expression,  gestures,  or 
actions  of  the  patient.  Voice-hearing  patients  often  assume  an 
attitude  of  listening,  or  turn  their  eyes  or  head  suddenly  round 
without  any  cause  apparent  to  the  onlooker,  or  even  reply  aloud 
to  the  voice  or  voices.  These  "voices"  are  frequently  found  in 
persecutory  or  suspicious  delusional  insanity,  and  are  often  the 
danger-signal  of  violence,  homicide,  or  suicide.  Patients 
suffering  from  visual  hallucinations  often  suddenly  look  at  a 
blank  wall  or  empty  corner  with  a  surprised,  frightened,  angry, 
or  amused  expression  ;  this  is  often  observed  in  delirium  tremens 
and  other  forms  of  alcoholic  mental  derangement.  Hallucinations 
and  illusions  of  taste  and  smell  are  generally  disagreeable,  and 
cause  the  patient  to  assume  a  facial  expression  of  disgust 
(delusional  insanity,  masturbatory  insanity,  delusional  melan- 
cholia). Hallucinations  and  illusions  of  the  general  sensibility, 
formication,  itching,  pricking,  stinging,  blows,  etc.,  may  be 
betrayed  by  the  patient  rubbing  or  scratching  the  part,  no 
vermin,  skin  disease,  or  bruises  being  present  (delusional  insanity, 
general  paralysis,  melancholia,  chronic  mania).  If  possible, 
examine  fundus  oculi,  test  grip  or  hand-grasp,  on  both  sides, 
with  dynamometer,  and  investigate  the  condition  of  the  special 
senses  as  to  their  acuteness,  dulness,  etc. 


152  DIAGNOSIS. 

To  INVESTIGATE  THE  ACUTENESS,  ETC.,  OF  THE   VARIOUS  SENSES. 

(1,)  The  cutamous  semiUlity  is  best  tested  according  to 
Gowers'  suggestion,  by  means  of  a  quill,  the  sharp  end  being  used 
for  the  sense  of  pain,  the  feathered  end  for  that  of  touch.  The 
sesthesiometer  may  be  applicable  in  a  few  cases. 

(2,)  The  sense  of  sinell  may  be  tested  by  means  of  such  simple 
well-kno'nm  articles  as  pepper,  tobacco,  onions,  eau-de-cologne,  the 
patient's  eyes  being  kept  closed  duiing  the  examination,  and  each 
nostril  tried  sejDarately.  For  testing  this  sense  the  French  have 
invented  a  "  bolte  aux  odeurs." 

(3,)  Taste  may  be  investigated  by  means  of  camel-hair  brushes 
dipped  in  solutions  of  sugar,  salt,  citric  acid,  and  quinine,  both 
sides  of  the  tongue  being  separately  tested. 

(4,)  The  sense  of  hmring  may  be  fairly  well  tested  by  means  of 
a  watch  held  at  various  distances,  commencing  mth  actual 
contact  at  the  vertex  of  the  head,  or  behind  the  ear,  and  ^nth- 
draAving  it  gi^adually  until  the  ticking  is  no  longer  heard,  this 
distance  being  noted  for  each  ear.  Musical  notes,  high  and  low, 
may  also  be  used. 

(5,)  Visiou  may  be  roughly  tested  (one  eye  at  a  time)  by 
means  of  the  ordinary  tests  :  types  at  various  distances  for 
acuteness ;  by  coloured  wools  for  the  colour  sense  ;  and  by  the 
hand  of  the  examiner  held  above,  below,  and  at  each  side  of  the 
eye  under  examination,  at  various  distances,  the  eye  being  fixed 
on  that  of  the  examiner,  for  the  field  of  'vasion. 

(6,)  The  sense  of  muscular  resistance  ought  to  be  tested. 

(7,)  The  electric  sensibility  should  be  tested. 

(8,)  The  state  of  the  muscular  sense  may  be  ascertained  by 
placing  the  limb  in  any  position  and  asking  the  patient  (whose 
eyes  are  closed)  to  put  the  other  limb  in  a  similar  posture. 

(9,)  The  cutaneous  thermic  sensihility  should  be  tested. 

The  pupils  should  be  examined  as  to  their  size,  equality,  regu- 
larity, light  reflex,  skin  reflex,  and  accommodation  reaction. 

The  reflexes,  superficial  and  deep,  especially  the  latter  (ankle 
clonus  and  knee-jerk),  ought  to  be  carefully  investigated,  and 
their  presence  or  absence,  extent  and  duration,  noted. 

The  reactions  of  the  muscular  and  nervous  apparatus  to  faradism 
and  galvanism  are  to  be  ascertained.  ^ATien  there  is  paralysis  the 
presence  of  E.  D.  is  imjDortant. 

The  patient's  height  and  v:eight  should  be  noted,  and  his  head 
measui^ed  as  to  the  length  of  its  antero-jDOSterior  and  transverse 
curves,  its  horizontal  circumference  (most  important),  its  diameters 


DIAGNOSIS.  153 

antero-posterior  and  transverse ;  by  multiplying  the  latter  dia- 
meter by  100  and  dividing  by  the  former  the  cephalic  index  is 
obtained  (Morselli).  The  condition  of  the  general  sensiUlity,  of  the 
sexual  organs,  and  of  the  masticatory  app>amtus  should  be  ascer- 
tained. In  mental  diseases  accompanied  by  hypokinesis,  tremor, 
or  ataxy,  Morselli's  chjnamograph  gives  useful  diagnostic  indica- 
tions. The  patient's  ^^ reaction  time"  should  when  possible  be 
ascertained.  According  to  H.  Miinsterberg  ("Beitrage  zur 
experimentellen  Psychologie  ")  coffee  and  (when  taken  slowly  in 
small  sips)  alcohol  shorten  reaction  time.  Alcohol  in  larger 
quantity  delays  it,  though  to  the  subject  of  experiment  it  always 
appears  to  hasten  it.  It  is  delayed  also  by  fatigue,  epilepsy,  and 
mental  disease  ("Brit.  Med.  Journ.,"  July  11,  1891,  p.  81).  The 
blood  should  be  examined  chemically  as  well  as  by  means  of  Gowers' 
hsemoglobinometer  and  hsemacytometer,  and  the  microscope. 

Desceiption  of  Mental  and  Bodily  Condition  on  Admission. 

The  Commissioners  in  Lunacy  direct  that  the  following  particulars 
should  be  entered  in  the  Medical  "Case  Book"  kept  in  every 
asykim,  licensed  house,  and  lunatic  hospital.  This  mil  be  a  guide 
to  the  first  entry  after  admission,  to  be  made  in  a  blank  page  at  the 
beginning  of  the  Medical  Visitation  Book  required  to  be  kept  where 
there  is  a  single  jDatient.  It  will  also  be  a  guide  as  to  the  method  of 
"taking  "  a  mental  case. 

"  1st. — A  statement  to  be  entered  of  the  name,  age,  sex,  and 
previous  occupation  of  the  patient,  and  whether  married,  single,  or 
widowed. 

"2nd. — An  accurate  description  to  be  given  of  the  external  appear- 
ance of  the  patient  upon  admission  ;  of  the  habit  of  body  and  tem- 
perament, and  appearance  of  eyes,  expression  of  countenance,  and 
any  peculiarity  in  form  of  head  ;  physical  state  of  the  vascular  and 
respiratory  organs,  and  of  the  a,bdominal  viscera,  and  their  respec- 
tive functions  ;  state  of  the  pulse,  tongue,  skin,  etc. ;  and  the  presence 
or  absence  on  admission  of  bruises  or  other  injuries,  to  be  noted. 

"  3rd. — A  description  to  be  given  of  the  phenomena  of  mental 
disorder  ;  the  manner  and  period  of  the  attack ;  with  a  minute 
account  €)f  the  symptoms  and  the  changes  produced  in  the  patient's 
temper  or  disposition,  specifying  whether  the  malady  displays  itself 
by  any,  and  what,  illusions,  or  irrational  conduct,  or  morbid,  or 
dangerous  habits  or  propensities ;  whether  it  has  occasioned  any 
failure  of  memory  or  understanding,  or  is  connected  ^vith  epilepsy, 
or  ordinary  paralysis,  or  symptoms  of  general  paralysis,  such  as 
tremulous  movements  of  the  tongue,  defect  of  articulation,  or  weak- 
ness or  unsteadiness  of  gait. 

"  4th. — Every  particular  to  be  entered  which  can  be  obtained 
respecting  the  previous  history  of  the  patient ;  what  are  believed 
to  have  been  the  predisposing  and  exciting  causes  of  the  attack  ; 
what  the  previous  habits,  active  or  sedentary,  temperate  or  other- 
wise ;  whether  the  patient  has  experienced  any  former  attacks,  and, 


154  DIAGNOSIS. 

if  so,  at  what  periods  ;  whether  any  relatives  have  been  subject  to 
insanity ;  and  whether  the  j)resent  attack  has  been  preceded  by  any 
premonitory  symptoms,  such  as  restlessness,  unusual  elevation  or 
depression  of  spirits,  or  any  remarkable  deviation  from  ordinary 
habits  and  conduct ;  and  whether  the  patient  has  undergone  any, 
and  what,  previous  treatment,  or  has  been  subjected  to  personal 
restraint." 

B.— DIFFERENTIAL  DIAGNOSIS  OF  THE  FORMS  OF 
INSANITY. 

The  operations  of  the  nervous  centres  obtain  expression  imme- 
diately or  remotely  through  the  medium  of  the  muscular  system. 
The  methods  by  which  they  do  so  are  various,  e.g.,  facial 
expression ;  gestures ;  attitudes ;  actions,  constituting  habits 
and  conduct ;  language,  written  or  spoken.  The  latter  (spoken 
language  or  speech),  as  by  means  of  it  we  most  readily,  accurately, 
and  fully  gauge  the  thoughts  and  feelings  (including  their 
extent,  aberration,  or  absence),  especially  in  the  insane,  will 
be  here  used  as  the  leading  test  in  formulating  a  rough  scheme  of 
differential  diagnosis. 

In  making  a  diagnosis  the  more  common  forms  should  be 
borne  in  mind  :  statistics  of  their  relative  frequency  will  be  found 
at  the  end  of  this  chapter. 

The  possibility  of  the  co-existence  of  one  or  more  forms  should 
also  be  remembered.  One  or  more  symptoms  of  any  form  may 
be  slightly  marked  or  absent. 

When  the  patient  is  appropriately  questioned,  he  either 
answers  the  questions  or  he  does  not  (either  through  incapacity 
or  unMdllingness,  mostly  the  former). 

I. — The  Patient  Answers  Questions. 

-Under  this  head  will  come  : — Delusional  insanity  (monomania, 
paranoia)  ;  impulsive  insanity  ;  moral  insanity  ;  folie  raisonnante  ; 
simple  mania ;  most  cases  of  hysterical  insanity ;  phthisical 
insanity  ;  insanity  with  paralysis  agitans  ;  mild  melancholia ; 
mania  in  all  its  forms  (not,  of  course,  including  acute  delirium) ; 
neurasthenia  and  most  cases  of  neurasthenic  insanity ;  masturba- 
tional  insanity;  imbeciles  and  higher  class  of  idiots  ;  gastro-enteric 
insanity  ;  insanity  of  abdominaJ  diseases  ;  insanity  of  Bright's  dis- 
ease ;  ansemic  insanity ;  insanity  from  deprivation  of  senses  ;  partial 
emotional  aberration  ;  partial  exaltation ;  folie  du  doute  ;  gouty 
insanity  ;  general  paralysis,  except  near  termination  ;  ovarian  or 
old  maid's  insanity.  Most  cases  of  acute,  religious,  delusional, 
and  suicidal  melancholia  ;  pellagroiis  insanity  ;  diabetic  insanity  ; 
climacteric   insanity ;    deliriimi  tremens  and  acute   opium   and 


DIAGNOSIS.  155 

morphia  insanity ;  katatonia,  except  cataleptic  phases ;  hypo- 
chondriacal melancholia  (hypochondriacal  insanity)  ;  insanity  of 
phosphaturia  and  oxaluria  ;  insanity  from  cannabis  indica ;  ges- 
tational, lactational,  and  puerperal  insanity ;  some  cases  of 
delirium  of  young  children ;  traumatic  insanity  ;  post-connubial 
insanity ;  periodical  insanity ;  circular  insanity  ;  pubescent  and 
adolescent  insanity  ;  choreic  insanity  ;  insanity  with  exophthalmic 
goitre  ;  primary  mental  deterioration  ;  chronic  alcoholic  insanity  ; 
alcoholic  dementia  ;  alcoholic  dementia  with  paraplegia  (mostly 
occurring  in  females) ;  senile  insanity ;  insanity  from  coarse  brain 
disease ;  alcoholic,  syphilitic,  and  saturnine  pseudo-general  para- 
lysis ;  epileptic  dementia  ;  insanity  of  myxoedema ;  some  cases  of 
rheumatic  insanity  ;  insanity  from  chloral  hydrate ;  saturnine 
insanity ;  primary  and  secondary  confusional  insanit}^. 

1. 

The  patient  answers  questions  and  can  sustain  a  conversation. 

The  memory  is  not  very  defective,  and  the  power  of 

calculation  is  little,  if  at  all,  diminished. 

A. — There  are  systematised,  fixed,  and  permanent  delusions, 
and  no  marked  emotional  aberration. 

The  forms  of  insanity  coming  under  this  head  are  delusional 
imanity  (monomania,  paranoia) ;  phthisical  insanity  ;  some  cases  of 
insanity  with  paralysis  agitans ;  some  cases  of  goiity  insanity ;  some 
cases  of  chronic  morphismus ;  ovarian  or  old  maid's  insanity ;  and 
some  cases  of  consecutive  inscmity. 

In  Phthisical  Insanity  there  are  delusions  of  suspicion.  Physi- 
cally, there  are  pallor,  sallowness,  emaciation,  and  frequently 
thoracic  signs  and  tuberculous  heredity.  Sometimes  the  signs  of 
phthisis,  or  frequent  pulse  and  fever,  with  evening  exacerbations. 

In  some  cases  of  Insanity  of  Paralysis  Agitans  there  are 
delusions  of  suspicion  and  persecution.  It  may  be  distinguished 
from  monomania  by  the  presence  of  the  tremors,  which  occur  in 
advanced  life  (over  40),  continue  during  rest,  and  do  not  affect 
the  head. 

Cases  of  Gouty  Insanity  resembling  persecutory  monomania 
may  be  diagnosed  by  the  existence  of  the  gouty  diathesis,  the 
history  of  gout,  and,  as  a  rule,  by  the  gouty  heredity.  Advanced 
life.     Male  sex. 

The  persecutory  delusional  insanity  of  Chronic  Morphismus 
may  be  distinguished  by  the  history  of  prolonged  and  persistent 
morphia  intoxication.  It  is  accompanied  by  auditory  hallucina- 
tions and  sensations  of  "galvanic  shocks." 


156  DIAGNOSIS. 

Ovarian,  or  Old  Maid's  Insanity  resembles  erotomania,  or 
delusional  insanity  "\vitli  erotic  delusions,  and  may  be  included  in 
that  form  of  insanity,  but  it  always  breaks  out  shortly  before  the 
climacteric  in  a  person  who  has  been  previously  exceedingly 
modest  and  discreet,  some  clergyman  being  generally  the  object 
of  affection. 

In  delusional  insanity,  or  monomania,  the  delusions  may  refer 
to  :— 

(1,)  Persecution  or  suspicion.  This  form  has  to  be  distin- 
guished from  those  just  mentioned  and  from  melancholia  with 
delusions  of  persecution.  In  the  latter  there  are  the  inability  to 
sustain  a  conversation  and  the  overwhelming  emotional  depression. 
In  monomania  (paranoia)  there  are  frequently  somatic  stigmata, 
such  as  cranial  anomalies,  etc.,  and  there  is  generally  a  strong 
neurotic  heredity.  The  delusions  of  neurasthenic  paranoia  arise 
out  of  the  neurasthenic  sensations. 

(2,)  Pride  or  ambition. 

(3,)  Religion.  These  forms  (2  and  3)  may  be  differentiated 
from  partial  exaltation  by  the  emotional  exaltation  in  the  latter 
being  more  prominent  than  the  delusions. 

(4,)  Jealousy.  In  alcoholic  jealoiisy  there  is  an  alcoholic 
history.  There  are  delusions  of  mutilation  of  the  sexual  organs 
and  of  poisoning  (>Spitzka). 

(5,)  Erotism  (erotomania).  To  be  distinguished  from  nympho- 
mania and  satyriasis,  which  are  morbid  impulses,  not  necessarily 
coimected  "ndth  delusions.  To  be  distinguished  also  from  the 
mere  strong  erotic  tendency  of  acute  mania,  early  general  para- 
lysis, etc. 

B. — There  are  unsystematised,  fixed,  and  jDermanent  delusions, 
motor  excitement,  and,  at  times,  emotional  exaltation.  The 
mental  condition  is  secondary  to  a  more  acute  one.  There  is  a 
constant  and  gradually  increasing  tendency  towards  dementia. 
This  includes  the  better  and  earlier  cases  of  chronic  mania  and 
some  cases  of  chronic  hysterical  iasaniti/. 

C. — There  are  morbid  impulses  without  delusions  and  without 
any  continuous  morbid  emotional  state.  This  group  constitutes 
irapuldve  insanihj,  including  destructive  mania,  dipsomania, 
homicidal  mania,  kleptomania,  lycanthropia,  necrophilism, 
nymphomania,  planomania,  pyromania.  satyriasis,  suicidal  mania. 

As  forms  of  insanity  these  should  be  distingTiished  from  the 
mere  symptomatic  actions  of  mania,  melancholia,  etc.  As 
forms  of  insanity  they  exist  "wdthout  any  other  apparent 
symptoms. 

D. — Change  of  habits,  disposition,  and  demeanour.  The 
committal  of  vicious  and  cruel  deeds  :    viciousness  and  wanton 


DIAGNOSIS.  157 

cruelty  are  also  sometimes  congenital.  There  are  no  delusions  or 
hallucinations.  The  disease  is  moral  insanity  :  distinguished  from 
monomania  by  the  absence  of  delusions  ;  from  impulsive  insanity 
by  the  nature  of  the  acts,  and  by  their  being  committed  when 
the  opportunity  rises,  and  not  when  the  patient  is  seized 
with  a  sudden  impulse  ;  from  simple  mania  by  the  absence  of 
exaltation,  and  by  not  being  preceded  or  succeeded  by  acute 
mania. 

E. — Change  of  habits,  with  exaltation  and  ill-regulated  con- 
duct. There  are  no  delusions  or  hallucinations.  Sometimes 
precedes,  sometimes  follows  acute  mania  ;  occasionally  remains 
unaltered  many  years,  having  commenced  as  a  primary  affection. 
The  form  of  insanity  is  simple  mania.  For  differential  diagnosis, 
see  preceding  paragraphs.  Some  cases  of  chronic  hysterical  insanity 
and  some  cases  of  gouty  insanity  resemble  simple  mania. 

F. — Change  of  habits,  etc.,  mth  de^oression.  There  are  no 
delusions  or  hallucinations. 

(a,)  Without  any  essential  bodily  defect  or  disorder.  Mild 
melancholia;  mild  chloral  insanity ;  some  cases  of  ]n'^^sc£nt  and 
adolescent  insanity  ;  neurasthenia,  distinguished  by  tremor,  noso- 
phobia, feeling  of  prostration,  reactivity,  etc.  ^ 

(b,)  With  disease  of  abdominal  organs.  Gastro-enteric  insanity  ; 
insanity  of  abdominal  diseases;  and  earl}-  stage  of  insanity  of 
Brighfs  disease. 

(c,)  With  anaemia.  Most  cases  of  a/iuemic  insanity.  In  some 
cases  of  anaemic  insanity  there  is  slight  stupor  ;  in  others,  an 
alternating  maniacal  condition. 

{d,)  With  catalepsy.     Mild  cases  of  caJcdeptic  insanity. 

{e,)  With  deprivation  of  the  senses.  Mild  cases  of  insanity 
from  dejvivcttion  of  the  senses. 

(/,)  Some  cases  of  podagrous  or  gaiity  insanity.  The  bodily 
disorders  and  defects  must  be  the  cause  and  not  the  effect,  or 
mere  concomitant  of  the  emotional  depression. 

{g,)  Alternating  with  periods  of  excdtation.  Mild  cases  of  folic 
circtdaire.  According  to  Falret  persons  may  suffer  from  a  mild 
form  unknown  to  their  entourage. 

G. — There  is  congenital  abulia  (weakness  of  will)  combined 
with  abnormally  strong  propensities.  As  a  rule  there  are  somatic 
stigmata.  The  patient  is  weak-minded,  or  one  of  the  higher  class 
of  imbeciles. 

H. — There  is  depression,  preceded  by  restlessness,  and  suc- 
ceeded by  acute  maniacal  excitement,  and  occurring  in  youth. 
There  are  disagreeable  hallucinations  of  smell  and  sometimes 
of  taste,  these  symptoms  supervening  on  the  habit  of  mastiu'- 
bation.     Masturbatiomd  insanity  in  its  early  stages. 


]  58  DIAGNOSIS. 

I. — The  patient  is  given  to  doubting,  and  is  perplexed  and 
vacillating.  He  is  introspective,  probably  apprehensive,  and 
frequently  asks  the  same  questions.  He  is  gloomy,  dreamy,  and 
punctilious,  and  pays  extreme  attention  to  all  his  words  and 
acts.  The  patient  suffers  from  folie  du  doide  {doubting  insanity, 
doubting  mania).  These  jDatients  may  be  metaphysicians 
(sufferers  from  griibelsucht),  realists,  scrupulous,  timid,  counters, 
or  touchers. 

J. — There  is  morbid  feeling,  usually  fear  or  apprehension, 
some  abulia  (weakness  of  vnW),  and  no  delusions  or  hallucinations. 
The  patient  is  suffering  from  jxirticd  emotional  aberration,  some 
of  the  forms  of  Avhich  are  agoraphobia,  claustrophobia,  myso- 
phobia. 

K. — There  is  a  morbid  state  of  emotional  exaltation.  This  is 
partial,  and  is  one  of  pride,  A'anity,  or  religious  feeling.  There 
may  be  delusions,  but  they  are  secondary  to,  and  less  prominent 
than,  the  emotional  state.  The  patient  suffers  from  partial 
excdtation  or  ameno/nania. 

Li. — There  are  unsystematised,  fixed,  and  permanent  delusions, 
mosth'  resembling  those  of  melancholia,  sometimes  those  of 
mania.  There  is  an  absence  of  emotional  exaltation  and  motor 
excitement.  The  state  is  secondary  to  melancholia,  mania,  or 
primary  confusional  insanit}^,  and  there  is  a  constant  and 
gradually  increasing  tendency  tOAvards  dementia.  It  is  chronic 
confusional  insanity  (Spitzka) ;  generally  included  in  chronic  mania 
by  other  alienists. 

M. — There  are  change  of  habits,  readily  induced  muscular 
fatigue,  increased  susceptibility  to  the  effects  of  alcohol,  fine 
fibrillary  tremor  of  tongTie,  and,  perhaps,  of  lips  and  face,  various 
neuralgiae,  some  depression,  sometimes  pupillary  inequality. 
Prodromcd  stage  of  general  parahjsis  ;  remission  of  genercd  paralysis  ; 
in  latter,  often  mendacity  and  irritability,  and  there  may  be 
slight  exaltation  instead  of  depression. 

N". — The  patient  may  be  able  to  sustain  a  conversation,  and  be 
free  from  delusions  and  hallucinations,  but  mth  a  history  of 
attacks  of  exaltation,  depression,  alternating  exaltation  and 
depression  "svith  short  intervening  lucid  intervals,  or  epilepsy  or 
epileptic  vertigo  T\ith  motor  excitement  and  unconsciousness  or 
semi-consciousness.  He  is  in  one  of  the  lucid  intervals  of 
periodical  insanity,  folic  altcrnante,  folie  d  double  fornw,  or  epileptic 
insanity. 

O.— There  are  perversions,  delire  des  actes,  etc.,  yet  the 
patient  is  able  to  talk  sensibly  and  to  excuse  his  foolish  acts  Avith 
shrewdness.  There  is  marked  periodicity.  There  are  degenera- 
tive signs.     Maniacal  folie  raisonnante  (mild  periodical  mania). 


DIAGNOSIS.  159 

P. — There  are  depression,  ill-humoui^,  quarrelsomeness, 
aggravated  at  the  menstrual  periods.  Melancholy  folie  raison- 
nante.  Most  of  these  cases  are  neurasthenic  and  degenerative. 
(For  signs  of  degenerative  taint,  see  "  Periodical  Insanity." 
Chap.  III.) 

Q,. — The  patient  has  no  initiative,  no  originating  power,  no 
active  desires,  no  power  of  self  guidance  or  resisting  capacity  ;  or 
he  may  have  complete  loss  of  memoiy  of  recent  events,  with  good 
memory  of  long  past  events.  He  is  suffering  from  partial  dementia, 
succeeding  mania,  or  melancholia.  Some  of  these  cases  belong 
rather  to  the  next  group. 

2. 

The  patient  answers  questions,  but  cannot  sustain  a  conversation. 
The  memory  is  markedly  defective,  the  power  of  cal- 
culation is  much  diminished,  and  the  ideas  of 
time  and  locality  are  vague. 

A. — -Absent-mindedness,  general  inertia,  insomnia,  forgetfulnef  s 
of  recent,  and  afterwards,  if  recovery  does  not  take  place,  of  both 
recent  and  long  past  events ;  the  symptoms  occurring  in  young 
or  middle-aged  persons  as  a  pnimary  affection.  The  patient  suffers 
from  primary  mentcd  deterioration  {simple  primary  dementia),  the 
primary  partial  dementia  of  Savage.  In  some  cases  of  consecutive 
insanity  the  symptoms  are  similar  to  those  of  primary  mental 
deterioration.  Mild  cases  and  insipient  ones  belong  rather  to 
group  I.,  1. 

B. — History  of  prolonged  addiction' to  drink,  tremors,  painful, 
mobile,  nocturnal  hallucinations,  or  (especially  in  women)  weak- 
ness of  lower  extremities.  Chronic  cdcoholic  insanity,  alcoholic 
dementia,  cdcoholic  dementia  with  paraplegia  (last  form  occurs 
mostly  in  women). 

C. — Occurring  as  a  primary  affection  in  middle  or  old  age,  with 
a  long  past  history  of  syphilis.  With  or  without  incoherence. 
Depressive  syphilitic  insanity. 

D. — Occurring  as  a  terminal  affection,  succeeding  mania, 
melancholia,  etc.  Old  faces  and  long  past  events  are  remembered 
better  than  new  or  recent  ones  during  the  earlier  stages  of  the 
affection,  but  all  memory  is  finally  lost.  The  form  of  insanity  is 
terminal  dementia. 

E. — Occurring  in  old  age  (generally  after  60),  and  being- 
accompanied  by  egotism,  ideas  of  suspicion,  parsimony,  senile 
tremor,  etc.  The  loss  of  memory  of  recent  events,  side  by  side 
with  a  remarkable  recollection  of  long  past  occiu-rences,  is  most 


160  DIAGNOSIS. 

marked  in  this  form  of  insanity,  especially  in  the  early  stages ; 
later  on  the  memory  ceases  to  recall  even  long  past  events. 
Senile  dementia  is  the  form  of  insanity. 

F. — The  mental  state  frequently  follows  a  paralytic  or  apoplec- 
tic attack.  It  is  generally  accompanied  by  paralysis,  or  some 
muscular  weakness,  and  sometimes  by  aphasia  (organic  dementia). 
Occasionally  the  paralytic  or  apoplectic  seizure  is  preceded  and 
followed  by  depression,  the  motor  symptoms  supervening  after 
the  seizure  (organic  melancholia).  In  insanity  from  coarse  brain 
disease  the  speech  is  thick,  but  equally  so  from  beginning  to  end 
of  a  sentence,  Avhilst  the  defect  increases  at  the  end  in  general 
paralysis.  Speech  is  not  accompanied  by  labial  and  facial  tremor 
as  in  general  paralysis.  In  the  form  caused  by  tumour  (which 
much  resembles  general  paralysis)  there  is  very  intense 
cejDhalalgia.  Insanity  from  coarse  brain  disease  (organic  dementia, 
organic  melancholia). 

G. — Tremor  of  tongue,  lips,  and  face  ;  speech  thick,  stammer- 
ing, or  stuttering ;  defective  gait ;  cutaneous  anaesthesia ;  pupils 
frequently  unequal ;  very  often  grandiose  delusions.  The  defect 
of  memory  applies  both  to  long  past  and  recent  events,  and 
increases,  as  does  the  defect  in  the  power  of  calculation  and  the 
vagueness  of  the  ideas  of  time  and  space.  Found  in  patients 
aged  from  20  to  60,  especially  35  to  45.  Under  this  head  come 
confirmed  genercd  jmralysis,  alcoholic  psemlo-genercd  paralysis,  syphilitic 
p)seudo-genercd  parcdysis,  and  scdurnine  pseudo-genend  paralysis. 
Alcoholic  pseudo-general  panxdysis  is  distinguished  by  the  anorexia, 
by  the  tremor  being  general  and  massive,  by  the  paralysis  com- 
mencing at  the  extremities  of  the  members,  by  the  history  and 
symptoms  of  alcoholic  intoxication,  by  the  visual  hallucinations, 
and,  finally,  by  the  tendency  to  amelioration,  which  soon  shows 
itself. 

Syphilitic  pseudo-general  2>arcdysis  is  distinguished  by  the  mental 
symptoms  frequently  following  one  or  several  apoplectiform  or 
epileptiform  attacks  ;  by  the  frequent  absence  of  tremor  ;  by  the 
paralysis  being  more  accentuated  than  in  general  paralysis,  and 
partial  paralysis,  such  as  ptosis,  etc.,  being  more  frequent ;  by 
the  evolution  being  less  regular  than  in  general  paralysis,  by  the 
frequent  presence  of  a  very  pronounced  syphilitic  cachexia,  by 
the  mental  state  being  rather  brutish  or  stupid  (though  some- 
times extravagant)  than  expansive,  and  finally  by  the  possibility 
of  cure. 

Saturnine  pseudo-general  paralysis  is  distinguished  by  the  symp- 
toms of  saturnine  intoxication,  blue  line  on  gums,  colic,  cramps, 
earthy  hue  of  skin,  cephalalgia,  etc.,  etc.  ;  by  the  presence  of 
insomnia  and  nightmare,  by  the  visual  hallucinations  and  ideas  of 


DIAGNOSIS.  161 

persecution  and  poisoning,  by  the  dementia  manifesting  itself 
.suddenly  in  its  greatest  intensity,  and  by  the  tendency  to 
amelioration  making  itself  rapidly  felt. 

H. — Succeeding  repeated  attacks  of  acute  epileptic  insanity,  or 
as  a  consequence  of  epileptic  fits  continued  through  a  succession 
of  years.  The  patient  is  childish  and  addicted  to  onanism. 
Chronic  epileptic  insanity  or  epileptic  dementia. 

I. — Memory,  power  of  calculation,  facility  for  acquiring  new 
facts  and  accomplishments  below  normal  average  from  childhood. 
Noticing,  speaking,  walking  below  normal  average  from  infancy. 
Hand  reflex  absent  in  early  infancy.  There  are  somatic  stigmata, 
and  generally  insane,  neurotic,  or  alcoholic  heredity.  There  may 
be  delusions.  There  may  be  strong  propensities,  and  a  tendency 
to  emotional  excitement  on  slight  provocation.  Imbecility  and 
higher  cases  of  idiocy. 

J. — There  are  motor  excitement  and  loquacity  with  absence  of 
emotion.  The  patient  is  childish.  The  state  is  a  terminal  one, 
mania  being,  as  a  rule,  the  primary  form  of  insanity.  Agitated 
terminal  dementia. 

K. — Following  depression,  agitation,  delusions,  and  peculiar 
pathos  with  cataleptic  phases.  The  third  or  demented  stage  of 
katatonia. 

li. — Solitary,  unsocial,  and  impulsive.  Succeeding  acute 
maniacal  excitement.  Olfactory  hallucinations  occurring  in 
youth.     Final  stage  of  Masturhational  insanity. 

M.— There  are  delusions  of  persecution  and  physical  signs  of 
myxoedema.     Insanity  of  myxcedema. 

N. — With  acute  maniacal  excitement,  visual  hallucinations 
and  delusions  of  suspicion.  Occurring  usually  at  the  end  of  an 
attack  of  acute  rheumatism,  or  during  convalescence.  A  fcAV  cases 
of  rheumatic  insanity  (properly  so  called). 

O. — Maniacal  exaltation,  with  insomnia,  nocturnal  motor  rest- 
lessness, great  egotism,  suspiciousness.  Occurring  in  old  age. 
Senile  mania. 

P. — Acute  depression,  with  egotism,  delusions  of  suspicion  of 
an  ever-varying  yet  possible  nature  (things  being  stolen,  etc., 
etc.),  and  insomnia.     Occurring  in  old  age.     Senile  Melancholia. 

Q,. — Depression,  with  or  without  fits  of  excitement ;  visual 
hallucinations.  At  other  times  mild  or  furious  delirium.  There 
are,  or  have  been,  blue  line  on  gums,  colic,  constipation,  cephalal- 
gia, frequent  pulse,  and  insomnia.  No  pyrexia.  Most  cases  of 
saturnine  insanity. 

R. — There  are  unsystematised  fixed  delusions,  with  motor 
excitement,  and  episodical  emotional  exaltation.  The  state  is 
secondary  to    acute   mania,    and   the  delusions   resemble   those 

11 


162  DIAGNOSIS. 

found  in  that  form  of  insanity,  but  finally  become  a  mere  parrot- 
cry.  Advanced  chronic  mania  and  some  cases  of  chronic  hysterical 
insanity. 

S. — There  are  unsystematised  fixed  delusions,  generally 
resembling  those  of  melancholia,  sometimes  those  of  mania. 
There  is  frequently  a  change  in  the  sense  of  identity,  OAving  to 
the  failui^e  of  memoiy  and  logical  power ;  not  any  motor  excite- 
ment or  emotional  exaltation.  The  affection  is  secondary  to 
melancholia,  mania,  or  primary  confusional  insanity.  Advojiced 
chronic  confusional  insanity  (generally  included  under  head  of 
advanced  chronic  mania). 

T. — ^Depression,  with  suicidal  tendency.  Post  connubial 
insanity. 

XJ. — The  patient  cannot  fix  the  attention,  and  the  ideas  are 
mobile  and  futile.  Occurring  in  individuals  suffering  from  chorea. 
Mild  choreic  insanity. 

V. — Visual  and  auditory  hallucinations  are  frequent,  especially 
the  former,  and  when  maniacal  excitement  is  added  Ave  have 
severe  choreic  insanity. 

3. 

The  patient  answers  questions,  but  answers  them  irrelevantly, 
confusedly,  or  evasively,  and  cannot  sustain  a  conversation. 

A. — The  affection  is  primary,  and  the  patient  suffers  from 
hallucinations  and  delusions  (often  of  identity).  He  speaks 
incoherently  and  irrelevantly,  and  does  not  finish  his  sentences. 
There  is  an  absence  of  emotion,  but  at  first  the  memory  is  good, 
the  patient  being  able  to  relate  circumstances  (though  in  a  piece- 
meal, halting  manner)  occurring  immediately  before  the  attack  ; 
afterwaixls  he  speaks  of  himself  in  the  third  person,  or  manifests 
a  confused  double  consciousness.  The  affection  is  eminently 
curable.     It  is  primary  or  acute  confusioncd  insanity. 

B. — The  patient  sufters  from  a  form  of  stupor,  with  fits  of 
agitation.  There  are  automatic  movements  and  cries.  The 
patient,  when  urgently  questioned,  answers  confusedly  and 
evasively,  and  falls  again  into  a  state  of  torpor.  There  are  blue 
line  on  gums,  colic,  etc.  It  is  the  comatose  form  of  saturnine 
insanity. 

C. — There  are  tremor,  subnormal  temperature,  anxiety,  dulnes's 
of  perception,  blurring  of  consciousness,  isolated  delusions  giving 
rise  to  dreamy,  odd  actions.  The  psychosis  is  founded  on  a  basis 
of  accjuired  neurasthenia,  generally  cerebral.  Transitory  neuras- 
thenic psychoneurosis  (some  cases). 


DIAGNOSIS.  163 


4. 


The  patient  answers  questions,  but  cannot  sustain  a  conversation. 
There  is  marked  emotional  depression  or  exaltation. 

A. — There  is  emotional  exaltation,  with  motor  excitement 
and  incoherence,  with  or  without  delusions.  Acute  mania, 
maniacal  phase  of  circular  insanity,  periodical  mania,  i^wJesceji^ 
and  adolescent  insanity,  fully  developed  nuisturbafional  insanity, 
expansive  syphilitic  insanity,  piuerperal  mania  ;  most  cases  of  acnte 
hysterical  insanity.  Insanity  with  exophthcdmic  goitre,  fully  deve- 
loped insanity  of  BrigMs  disease,  nearly  one  third  of  the  cases  of 
uterine  or  arnenorrhceal  insanity,  some  cases  of  consecutive  insanity, 
maniacal  phase  of  general  paralysis.  Dui'ing  the  course  of  the 
latter  the  patient  is  facile  and  childish  ;  it  lasts  from  10  to  30 
days,  and  leaves  the  somatic  signs  of  general  paralysis.  According 
to  Rabbas  the  early  loss  of  reading  power  in  general  paralysis  is, 
like  the  alteration  in  writing,  of  great  use  in  making  a  differential 
diagnosis.  A  few  cases  of  gestational  insanity.  Some  cases  of 
metastatic  insanity.  These  can  generally  be  distinguished  from 
each  other  by  the  history  of  the  case,  the  sex  and  age  of  the 
patient,  the  circumstances  under  which  the  attack  has  occuiTed, 
the  jwesence  or  absence  of  some  neurotic  or  other  disease,  or 
of  some  physiological  condition,  or  characteristic  symptoms;  e.g., 
circular  and  periodical  cases  may  be  distinguished  from  the  others 
by  the  coherent  loquacity,  the  greater  frequency  of  illusions  than 
hallucinations,  the  rarity  or  absence  of  delusions ;  from  each 
other  by  the  anamnesia,  by  the  mechancetf^  of  the  former  and  the 
perversions  of  the  latter ;  periodical  mania  with  long  lucid  or 
sub-lucid  intervals  is  usually  severe  and  marked  by  some  elevation 
of  temperature.     (See  Chap.  III.) 

B. — There  is  extreme  emotional  depression,  with  self-abase- 
ment, with  more  or  less  suicidal  tendency,  with  or  without 
delusions,  and  without  motor  excitement.  Acute  melancholia, 
chronic  melancholia,  melancholy  phase  of  folic  circidaire  in  some 
cases,  diabetic  insanity,  some  cases  of  consecutive  insanity,  some  cases 
of  insanity  of  paralysis  agitans,  severe  chloral  insanity,  some  cases 
of  metastatic  insanity.  There  are  morbid  impulses  in  severe 
chloral  insanity.  Pellagrous  insanity.  Some  cases  of  acute  hysterical 
insoMity.  Several  of  these  forms  are  distinguished  by  the  diseases 
with  which  they  are  associated. 

C. — Emotional  depression  with  predominent  suicidal  tendency. 
Suicided  melancholia.     Some  cases  of  periodical  melancholia. 

D. — Depression,  with  suicidal  tendency  and  extreme  insomnia, 
with  or  without  delusions.     Occurrina;  in  women  from  40  to  50 


164  DIAGNOSIS. 

years  of  age,  and  occasionally  in  men  fiom  55  to  65.  It  succeeds 
a  period  of  shyness  and  various  nervous  and  dyspeptic  symptoms 
and  menstrual  irregularities.     It  is  climacteric  inmnity. 

E. — Emotional  depression,  tending  towards  an  irritable  and 
sometimes  dangerous  and  impidsive  dementia  or  delusional  in- 
sanity. There  are  cephalalgia,  vertigo,  hallucinations,  etc.  There 
are  also  motor  or  sensory  symptoms.  Alcohol,  for  which  there  is  a 
craving,  causes  violent  outbursts  of  excitement.    Traiuaatic  insanity. 

"F. — There  are  hallucinations,  painful,  mobile,  nocturnal,  the 
patient  seeing  animals,  devils,  etc.  There  are  muscular  tremors 
of  varying  intensity,  increased  by  the  ■\\dthdrawal  of  alcohol. 
There  may  be  pyrexia,  and  in  that  case  the  symptoms  resemble 
those  of  acute  delirious  mania  (acute  delirium),  but  in  acute 
delirium  the  patient  cannot  be  got  to  answer  questions.  The 
patient  is  suffering  from  delirium  tremens.  The  symptoms  of  acute 
opium  and  rnorplda  insanity  are  somewhat  similar,  but  the  tremor  is 
increased  by  the  ^WthdraAval  of  opium  or  morphia  respectively. 

G. — There  are  delusions  and  hallucinations  referring  to  the 
patient's  bodily  organs.  There  is  not  necessarily  any  tremor. 
There  is  no  self-abasement  and  no  suicidal  tendency.  Hypochon- 
driacal melancholia  (hypochondriacal  insanity).  In  insanity  of 
oxal'uria  and  j)^^osphaturia  oxalates  and  phosphates  are  found  in 
the  urine,  and  there  is  an  irritable,  nervous,  or  apprehensive 
state,  with  despondency,  but  no  actual  delusions  or  hallucinations. 

H. — There  are  extreme  emotional  depression  and  self-abase- 
ment. There  are  jDredominating  and  painful  delusions.  There 
is  often  strong  suicidal  tendency.  Delusional  melancholia,  most 
cases  of  gestational  and  lactational  insanity,  p)uerp)eral  melancholia, 
severe  insanity  from  deprivation  of  the  senses,  some  cases  of  syphilitic 
depression  with  incoherence ;  nearly  two-thirds  of  the  cases  of 
uterine  or  amenorrhcecd  insanity.  In  the  latter  there  are  disagreeable 
auditory  hallucinations. 

I. — There  are  great  emotional  depression,  agitation,  and  motor 
excitement.  Excited  or  agitated  melancholia;  some  cases  of  insanity 
oi  piaralysis  agitans  ;  some  cases  of  delirium  of  young  children. 

J. — There  is  great  emotional  depression,  and  the  predominat- 
ing delusions  refer  to  matters  connected  with  religion.  Religious 
melancholia. 

K. — At  first  there  is  depression,  with  or  A^thout  delusions  and 
hallucinations,  generally  of  a  painful  or  persecutory  nature. 
Then  there  are  atony,  j)eculiar  excitement,  confusion,  and  de- 
pression, combined  ^^Wth  a  peculiarj)athos,  and  alternating  almost 
cyclically.  There  is  verbigeration,  and  in  a  large  number  of  cases, 
there  are  spasmodic  conditions  during  the  first  stage.  The  first 
and  second  stages  of  katatonia. 


DIAGNOSIS.  165 

L. — There  are  emotional  exaltation,  motor  excitement,  and 
predominating  delusions  and  hallucinations.  Delusional  mania. 
Insanity  from  caivnahis  indica  (Gunjah,  Bang,  Hachish). 

M.- -Hampered  mental  action  rather  than  psychical  pain; 
nosophobia  in  early  stages ;  great  self-depreciation  in  the 
developed  disease  ;  olfactory  hallucinations  ;  suicidal  attempts  ; 
in  severe  forms,  filthy  habits,  fixed  ideas,  and  religious 
delusions.  The  disease  develops  on  a  basis  of  sexual  neuras- 
thenia. It  is  masturbatory  melancholia,  one  of  the  neurasthenic 
psy  chon  euroses. 


II. — The  Patient  does  not  Answer  Questions. 

1. 

The  patient,  though  he  cannot  be  made  to  answer  cpestions,  or 

to  understand  what  is  said  to  him,  is  very  loquacious, 

and  his  language  is  utterly  incoherent. 

A. — There  are  pyrexia,  furred  tongue,  weak  frequent  pulse,  and 
disturbances  of  speech  and  locomotion,  the  bodily  organs  being 
healthy.  Acnte  delirium  (acute  delirious  mania).  A  few  cases  of 
uterine  or  ainenoirheeal  insanity ;  some  cases  of  delirium  of  young 
children. 

B. — The  patient  is  very  loquacious,  his  language  is  incoherent, 
there  is  no  pyrexia,  and  the  attack  is  of  extremely  short  duration. 
Transitory  mania  (transitory  frenzy). 

C.-^The  patient  is  very  loc[uacious  and  talks  incoherently. 
The  attack  follows  immediately  the  imbibition  of  alcohol,  and  is 
of  short  duration.     There  is  no  pyrexia.     Mania  a  potu. 

D. — The  patient  is  very  loquacious,  talks  incoherently,  and 
frequently  repeats  the  same  phrases.  There  are  motor  agitation 
and  a  blindly  impulsive  tendency  to  violence,  homicide,  or 
suicide.  The  attack  occurs  in  connection  with  epilepsy. — Acute 
epileptic  insanity ;  attacks  of  excitement  in  chronic  epileptic 
insanity. 

E.— There  are  frightful  hallucinations,  and  the  attack  is  of 
short  duration,  and  terminates  abruptly.  Most  liable  to  occur 
episodically  in  cases  of  agitated  melancholia  developing  in 
alcoholic  sul^jects.     Melancholic  frenzy. 

F. — Occurring  mostly  in  old  persons  aff'ected  with  cyanosis, 
from  bronchitis,  cardiac  disease,  and  asthma,  and  often  passing 
into  torpor  and  coma.  Insanity  of  cyanosis,  from  bronchitis,  cardiac- 
disease,  and  asthma. 


166  DIAGNOSIS. 


2. 


The  patient  mutters  or  uses  isolated  words  or  phrases  habitually, 
but  cannot  answer  questions. 

A. — The  defect  is  congenital,  and  there  are  somatic  signs. 
Some  cases  of  idiocy. 

B. — There  is  emotional  depression.  The  affection  is  primary. 
Some  cases  of  melancholia. 

C. — There  is  mental  weakness.  The  affection  occurs  in  old 
age,  and  may  be  primary''  or  secondary,  generally  the  former. 
There  is  senile  tremor.     Advanced  senile  dementia. 

D. — There  is  mental  weakness,  secondary  or  tertiary.  Gener- 
ally occurring  in  middle  age,  but  may  be  prolonged  into  advanced 
life.  History  of  primary  exaltation  or  depression,  secondary 
mental  weakness  or  confusion,  epilepsy  or  general  paralysis. 
Advanced  terminal  dementia,  advanced  epileptic  dementia.  Some 
cases  of  general  paralysis  in  third  stage. 

3. 

The  patient,  although  he  understands  what  is  said  to  him,  and  is 
able  to  speak,  refuses  to  ansAver,  through  obstinacy,  ill- 
temper,  or  some  delusion  or  delusions. 

A.- — The  affection  is  congenital.  Some  cases  of  imbecility, 
especially  irnhecility  with  epiilepsy. 

B. — The  affection  is  acquired.  Some  cases  of  delusional  insanity 
(monomania,  paranoia).  Some  cases  of  hysterical  insanity.  In 
these  cases  (coming  under  head  3)  the  facial  expression  must 
be  noticed  when  annoying  or  ludicrous  propositions  are  made. 
The  patient's  dress,  demeanour,  and  actions  must  be  studied.  The 
history  of  the  case  should  be  brought  to  bear  on  the  diagnosis. 

4. 

The  patient  is  absolutely  mute. 

A. — There  is  an  absence  of  facial  expression.  The  pupils  are 
dilated.  The  patient  is  quite  passive.  The  limbs  remain  for  a 
long  time,  without  extraneous  support,  in  any  jiosition  in  which 
they  are  placed.  Cataleptic  p)hase  of  Jcatafonia.  Severe  form  of 
cataleptic  insanity.  In  the  former  case  the  condition  alternates  A^dth 
excitement,  etc.     In  the  latter  it  supervenes  on  a  cataleptic  attack. 

B. — There  is  an  absence  of  facial  expression.     The  pupils  are  ■ 
dilated.     The  patient  is  cjuite  passive.     The  limbs  when  raised 


DIAGNOSIS.  167 

and  then  let  go  obey  immediately  the  laws  of  gravity,  and  fall 
like  the  limbs  of  a  person  in  a  state  of  syncope.  Anergic  stupor 
(acute  primary  dementia).  A  few  cases  of  uterine  or  amenorrhceal 
insanity. 

C. — There  is  an  absence  of  facial  expression.  The  pupils  are 
dilated.  The  patient  is  not  passive,  but  inclined  to  resist  feeding, 
etc.  He  clenches  his  teeth,  compresses  his  lips,  etc.  He  resists 
being  taken  out  of  doors,  etc.,  etc.  Many  cases  of  stuporous 
melancholia  (melancholia  attonita).  Periodical  melancholia.  Most 
cases  of  rheunuUic  insanity,  properly  so  called.  Melancholic  phase 
of  folie  circulaire.  The  latter  when  severe  more  nearly 
approaches  gxoup  B  than  the  others,  and  it  alternates  with 
maniacal  attacks.  Unlike  group  B  consciousness  is  retained  ; 
this  is  shown  by  the  patients,  in  the  maniacal  phase,  talking 
about  what  they  have  heard  during  the  melancholy  period.  The 
rheumatic  form  follows  an  attack  of  rheumatism.  The 
periodical  melancholia  alternates  with  lucid  or  sub-lucid  inter- 
vals. 

D. — The  facial  expression  is  intelligent  or  ecstatic.  Some  few 
cases  of  delusional  insanity.  Some  cases  of  ]jarticd  insanity  or 
amenomania. 

E. — The  facial  expression  is  anxious  or  terrified.  Some  cases 
of  stuporous  melancholia  (melancholia  attonita).  These  cases  con- 
stitute, according  to  some  authorities,  a  distinct  group,  which 
they  name  delusional  stuporous  melancholia. 

F. — There  is  loss  of  perception,  consciousness,  memory,  and 
movement,  the  pupils  are  wide  and  sluggish  ;  the  pulse  is  small 
and  wiry  ;  the  temperature  subnormal.  Transitory  neurasthenic 
psychoneurosis  (some  cases). 

5. 

The  patient  is  unable  to  speak,  but  makes  inarticulate  noises. 

A, — The  affection  is  congenital,  and  accompanied  by  various 
bodily  diseases  and  defects.  Pronounced  cases  of  idiocy.  It  is 
sub-divided  into  genetous,  epileptic,  paralytic,  hydrocephalic, 
microcephalic,  eclampsic,  traumatic,  and  inflammatory  idiocy, 
idiocy  by  deprivation,  and  cretinism.  (See  "  Idiocy," 
chap.  III.) 

B. — The  patient  suffers  from  acquired  insanity  ;  makes  inarti- 
culate noises,  but  does  not  speak,  and  does  not  in  any  way  answer 
questions.  Last  stage  of  termincd  dementia.  The  ultimate  con- 
dition also  in  some  cases  of  epileptic,  senile,  syphilitic,  and  toxic 
insanity,  and  of  general  paralysis. 


168  DIAGNOSIS. 


EEFEEENCES     TO    PRECEDING    PARAGRAPHS    OF     THIS 

CHAPTER. 

Abdominal  Disorders,  Insanity  from,    I,  l.F. 

Adolescent  Insanity.     I.  l.F. — I.  i.A. 

Anaemic  Insanity.     I.  l.F. 

Bright's  Disease,  Insanity  of.     I.  l.F. — I.  4.A. 

Cataleptic  Insanity.     I.  l.F. — II.  4.A. 

Choreic  Insanity.     I.  2.U. 

Circular  Insanity.     II.  4.C.--1. 4.A.— I.  4.B.— I.  l.F. 

Climacteric  Insanity.     1. 4.D. 

Coarse  Brain  Disease,  Insanity  from.     1. 2.F. 

Confusional  Insanity,  primary  or  acute.     1. 3.A. 

Confusional  Insanity,  Chronic.     I.l.L. — I.2.S. 

Consecutive  Insanity.     I.  4.A. — I.  l.A. — I.  2.A. 

Cyanosis  from  Bronchitis,  Cardiac  Disease,  and  Asthma,  Insanity 
of.     II.  l.F. 

Delirium,  Acute.  II.  l.A. 

Delusional  Insanity  (Monomania,  Paranoia) .     I.  l.A. — II.4.D. 

Dementia  (Terminal).     1. 1.0— I.  2.D.— II.  5.B. 

Deprivation  of  Senses,  Insanity  from.     I.  l.F. — 1. 4.H. 

Deterioration,  Primary  Mental.     I.  2.A. 

Diabetic  Insanity.     I.  4.B. 

Epileptic  Insanity.     II.  I.D.— I.  2.H.— II.  5.B.— II.  2.D. 

Exophthalmic  Goitre,  Insanity  with.     1. 4.A. 

Folie  du  doute.     I.  l.I. 

Folie  Raisonnante.     1. 1.0. — I.  l.F. 

General  Paralysis.     I.  I.M.— I.  2.G.— II.  2.D II.  5.B.— I.  4.A. 

Gestational  Insanity.     1. 4.H. — I.  4.A. 

Hysterical  Insanity.     I.  I.E.— I.  4.B.  -I.  I.B.— I.  4.A.— I.  2.R.— II.  3.B. 

Idiocy,  Imbecility,  and  Cretinism.  I.  I.G.— II.  3.A. — 1. 2.1. — II.  2.A. — 
II.  5.A. 

Impiilsive  Insanity.     I.  l.C. 

Katatonia.     I.  4.K.— II.  4.A.— I.  2.K. 

Lactational  Insanity.     1. 4.H. 

Mania.     I.  I.E.— I.  4.A.— I.  4.L.— II,  I.B.— I.  I.B.— I.  2.R. 

Masturbational  Insanity.     I.  l.H. — I.  4.A. — I.  2.L. 

Melanchoha.  I.  l.F I.  4.B.— I.  4.C.— I.  4.G.— [I.  4.C.— II.  4.E.— I.  4.H. 

—I.  4.1 I.  4. J.— II.  I.E.— II.  2.B. 

Metastatic  Insanit3^     1. 4.A. —  I.  4.B.    (See  "  Rheumatic  Insanity.") 

Myxoedema,  Insanity  of.     I.  2.M. 

Neurasthenic  Insanity.  I.  l.F. — I.  3.C.— II.  4.F. — I.  4.M.  (See  "Anergic 
Stupor,"  "Acute  Confusional  Insanity,"  "Folie  du  doute," 
"Partial  Emotional  Aberration,"  "Delusional  Insanity" 
(Paranoia),  " Melancholy  Folie  Raisonnante"  (I.l.P.)  See  also 
"  Neurastlaenia  "  and  "  Neurasthenic  Insanity,"  Chap.  III.) 

Ovarian  or  Old  Maid's  Insanity.     I.  l.A. 

Oxaluria  and  Phosphaturia,  Insanity  of,     I.  4.G. 


DIAGNOSIS.  169 

Paralysis  Agitans,  Insanity  of.    I.  i.B. — I.  i.I. — I.  l.A. 
Partial  Dementia.     1. 1.0. 
Partial  Emotional  Aberration.     I.  l.J. 
Partial  Exaltation.     I.  I.K.— II.  i.D. 
Pellagrous  Insanity.     I.  4.B. 

Periodical  Insanity.    I.  4.A.— II.  4.C.— I.  I.N.— 1. 4.C.— I.  l.P. 
,  Phthisical  Insanity.     I.  l.A. 
Podagrous  or  Gouty  Insanity.     I.  I.E. — I.  l.F. 
Post-Connubial  Insanity.     I.  2.T. 
Pubescent  Insanity.     I.  l.F. — I.  4.A. 
Puerperal  Insanity.     I.  4.A. — I.  4.H. 
Rheumatic  Insanity.     II.  i.C. — I.  2.N. 
Senile  Insanity.     I.  2.O.— I.  2.P.— I.  2.E.— II.  5.B.— II.  2.C. 
Stupor,  Anergic.     II.  4.B. 

Syphilitic  Insanity.     I.  2.C.— I.  2.G.— I.  4. A.— II.  5.B.— I.  5.H. 
Toxic  Insanity.      I.  4.F.— I.  2.B.— I.  2.G.— II.  l.C— II.  5.B.— I.  l.F.— 

I.  4.B.— I.  i.L.  -I.  2.Q.— I.  2.G.— I.  3.B. 
Traumatic  Insanity.     I.  4.E. 

Uterine  or  Amenorrhoeal  Insanity.     I.  i.K, — I.  4.A. — II.  l.A. — II.  J.B  . 
Young  Children,  Delirium  of.     II.  l.A. — I.  4.1. 


FREQUENCY    OF    SOME    OF    THE    PRINCIPAL   FORMS    OF 

INSANITY. 

I. — On  Admission. 

Bucknill  and  Tuke,  quoting  Boyd,  give  : — 

Mania — 42*9  per  cent.  Idiocy — 4"3  per  cent. 

Melancholia — 18'4  per  cent.  Delirium  Tremens — 1'4  per  cent. 

Dementia — 10'6  per  cent.  Moral  Insanity — I'l  per  cent. 

Monomania — 5"3  per  cent.  Epilepsy — 10"9  per  cent. 
General  Paralysis — 5*1  per  cent. 

MALES.  FEMALES. 

Mania — 39*4  per  cent.  Mania  (including  Puerperal  Mania 

Melancholia — 15'2  per. cent.  6'0  per  cent.) — 46"3  per  cent. 

Dementia — 9*2  per  cent.  Melancholia — 21*6  per  cent. 

Monomania — 6-2  \)er  cent.  Dementia — 12-1  per  cent. 

General  Paralysis — 8-3  per  cent.     Monomania — 4*5  per  cent. 
Delirium  Tremens — 1-4  per  cent.    Idiocy — 3-1  per  cent. 
Moral  Insanity — 1-4  per  cent.  General  Paralysis — 2*0  per  cent. 

Epilepsy — 12-2  per  cent.  Moral  Insanity — 0-8  per  cent. 

Delirium  Tremens — 0*1  per  cent. 

Epilepsy — 9*5  per  cent. 

Clouston  gives  at  Royal  Edinburgh  Asylum  :  — 

Pubescent  Insanity — 4"6  per  cent. 
Adolescent  Insanity — B"?  per  cent. 

Climacteric   Insanity — 7*2   per  cent.,  of  which  :    Women — 6-2    per 
cent. ;  Men — !•  per  cent. 


1 70  DIAGNOSIS. 

Senile  Insanity — 6*4  per  cent.,  of  which  :  Women — 4*2  per  cent.  ; 

Men— 2-2. 
Paralytic  Insanity  (Insanity  from  Coarse  Brain  Disease) — 2-89  per 

cent. 
Phthisical  Insanity — 2*0  per  cent. 
Hysterical  Insanity — 1'08  -pev  cent. 
Masturbational  Insanity — 1"46  per  cent. 
Puerperal  Insanity — 1"9  per  cent. 
Lactational  Insanity — 1"2  per  cent. 
Gestational  Insanity — "47  per  cent. 
Traumatic  Insanity — -33  per  cent. 
Post-Febrile  Insanity — 1*   per  cent.,   of  which  '4  per   cent,   after 

Scarlatina. 
Folie  Circulaire,  less  than — -5  j)er  cent. 
Acute  Mania — 12 '49  j)er  cent. 

II. — Of  2,297  xDatients  at  the  New  York  Pauper  Asylum,  over  14  per 
cent,  were  terminal  dements  (Spitzka),  and  12*3  per  cent,  were 
paretic  dements  (General  Paralytics),  or  dements  with  organic  brain 
disease. 

Spitzka  found  2  per  cent,  of  over  2,000  male  kinatics  suffering 
from  Katatonic  Insanity. 

III. — Order  of   Frequency  at   Death. 

(Bucknill  and  Tuke.) 

Dementia  (frequently  General  Paralytic). — Mania  (usually  Chronic). 
— Melancholia. — Monomania. 

IV. — Several  forms,  such  as  Folie  du  Doute,  Partial  Emotional 
Aberration,  etc.,  are  seldom  met  with  in  asylums.  Many  cases  of 
Mild  Melancholia,  Senile  Insanitj^,  Insanity  from  Coarse  Brain 
disease.  Toxic,  and  Consecutive  Insanity  do  not  find  their  way  to 
asj^ums.  So  that  in  private  practice,  MelanchoHa  is  perhaj)S  met 
with  more  frequently  than  any  other  form  of  insanity. 


PROGNOSIS.  171 


CHAPTER   YI. 

.PROGNOSIS. 

A.~GENERAL  PROGNOSIS. 


I. — As  to  danger  to  life  : — 

(1,)  Unfavourable  when  serious  diseases  of  other  organs,  such 
as  tuberculosis,  heart  disease,  etc.,  are  present. 

(2,)  Unfavourable  when  general  paralysis  is  present.  As  a 
rule  fatal  in  from  one  to  three  years,  and  very  often  sooner 
(G-riesinger). 

(3,)  Unfavourable  when  there  are  extensive  and  intense  hyper- 
semias  of  the  brain,  which  very  rapidly  advance  to  softening,  and 
prove  almost  immediately  fatal  by  causing  serous  effusions, 
extravasation  of  blood,  etc. 

(4,)  (Edema  of  the  brain,  especially  if  it  comes  on  acutely  ; 
unfavourable. 

(5,)  Long  continued  refusal  of  food  unfavourable. 

(6,)  Much  greater  tendency  to  death  in  acute  melancholia  and 
acute  mania  than  in  the  chronic  forms,  or  monomania,  imbecility, 
etc. 

(7,)  Tendency  to  death  above  the  average  in  puerperal  or 
senile  insanity. 

(8,)  Strong  suicidal  tendency  unfavourable. 

(9,)  High  temperature  unfavourable. 

II. — As  to  recovery  from  mental  derangement.  The  consi- 
derations are  : — 

(1,)  T\iQ  form  of  insanitjj.     See  forms,  prognosis  of  (postea). 

(2,)  The  duration,  which  bears  an  inverse  ratio  to  the  recover- 
ability.  Clouston  gives  the  recovery  rate  of  patients  free  from 
organic  brain  diseases,  and  Avho  had  been  less  than  a  year  insane 
before  admission,  as  70  per  cent. 

(3,)  The  causes,  exciting  and  predisposing  ;  age  and  sex.  In 
hereditary  insanity  there  is  great  danger  of  relapse.     Prognosis 


172  PROGNOSIS. 

unfavourable  when  insanity  develops  gradually  in  a  person 
always  eccentric  (Griesinger).  Also  unfavourable  when  it  occurs 
after  years  of  vexation,  suspense,  etc.  Much  more  favourable 
when  arising  from  sudden  mental  shock,  fright,  etc.  Youth 
and  the  female  sex  influence  the  prognosis  favourably.  See- 
etiological  forms  of  insanity,  e.g.,  anaemic,  traumatic,  alcoholic, 
etc. 

(4,)  The  number  of  attacks.  Probability  of  permanent  cure 
diminishes  with  each  attack,  yet  many  patients  who  relapse 
repeatedly  recover. 

(5,)  The  external  circumstances  Siyii\.  relations  of  life  of  the  patient. 
Poverty  and  inability  to  have  change  of  surroundings  unfavour- 
able. 

(6,)  The  jjhysical  health  a.nd  condition.  Return  of  bodily  health 
unaccompanied  by  return  of  mental  sanity  unfavourable.  Stout- 
ness then  frequently  an  indication  of  tendency  to  dementia. 

(7,)  The  secretions.  Return  of  suspended  (especially  men- 
struation), favourable.  Profuse  secretions  sometimes  critical 
(Bucknill  and  Tuke). 

(8,)  The  course  of  the  disease.  Periodicity :  early,  with 
intervals  longer  than  paroxysms,  but  becoming  shorter  each  time, 
or  regular  periodicity,  unfavourable.  Shoit  lucid  intervals,  or 
remissions  gradually  becoming  longer,  favourable.  Gradual 
recovery  more  likely  to  be  permanent  than  sudden  return  to 
sanity. 

(9,)  The  presence  or  absence  of  certain  signs:  Somatic 
stigmata,  pai-alysis,  paresis,  convulsions,  onset  or  exacerbation 
at  physiological  periods,,  morbid  impulses  with  one  exception, 
morbid  propensities  occurring  alone,  moral  perversions  without 
other  symptoms,  affective  perversions  occurring  alone,  fixed  ideas, 
systematised  delusions,  fixed  delusions,  grandiose  delusions,  very 
defective  memory,  unconscious  delirium,  are  generally  un- 
favourable. Maudsley  says  that  the  homicidal  patient  with 
persecutory  ideas  seldom  recovers,  "  while  the  suicidal  patient 
generally  does  recover,  particularly  after  some  serious  and  all 
but  successful  suicidal  attempt."  With  regard  to  fixed  delusions 
Maudsley  says  the  prognosis  is  unfavourable  in  melancholies 
who  believe  their  troubles  are  caused  by  external  agency, 
but  more  favourable  in  those  who  attribute  their  suffering 
to  faults  of  their  own. 

(10,)  Ileturn  of  natural  affection  and  of  former  habits,  tastes, 
manner,  and  modes  of  speech,  ancl  the  patient's  recognition  of 
his  state,  past  and  present,  favourable. 

For  further  indications  for  prognosis  see  below,  under  heads 
"Mania"  and  "Melancholia." 


PROGNOSIS.  173 


B.— SPECIAL  PROGNOSIS  (INCLUDING  DUBATION). 

ADOLESCENT   INSANITY. 

Out  of  180  cases,  Clouston  only  knew  of  26  who  became  incur- 
able. He  therefore  looks  on  adolescent  insanity  as  very  curable 
compared  with  many  mental  disorders,  though  not  so  curaljle  as 
others,  e.g.,  puerperal  insanity.  An  inveterate  habit  of  mastur- 
bation renders  the  prognosis  more  serious,  especially  in  males. 
Clouston  is  inclined  to  give  a  favourable  prognosis  when  he  sees, 
accompanied  by  mental  improvement,  signs  of  physiological 
manhood  appearing :  the  beard  growing,  the  form  expanding,  the 
weight  increasing.     Only  three  of  his  180  cases  died. 

Of  B.  Lewis's  cases  nearly  three-foiurths  of  the  females  and 
nearly  three-fifths  of  the  males  recovered,  about  a  thirteenth 
of  the  former  and  a  seventh  of  the  latter  were  discharged  relieved, 
nearly  an  eighteenth  of  the  women  and  nearly  a  tenth  of  the 
men  died,  and  about  three-tenths  of  the  whole  number  remained 
in  the  asylum  as  chronic  patients.  Half  the  female  cases  that 
were  cured,  after  a  relapse  or  tAvo,  had  recovered  by  the  seventh, 
and  nearly  three-fourths  by  the  tenth,  month. 

ANJEMIC   INSANITY. 

80  per  cent,  of  Clouston's  cases  recovered,  most  of  them  within 
three  months. 

BRIGHT'S  DISEASE  {Insanity  of). 

In  a  case  quoted  by  Clouston  as  typical,  the  patient  only  lived 
about  two  months  after  the  appearance  of  his  mental  symptoms. 

CATALEPTIC  INSANITY. 

Speaking  of  catalepsy  (not  cataleptic  insanity)  Ross  states  that 
the  prognosis  is  unfavourable  with  respect  to  complete  recovery. 
Cases  arising  from  malaria,  injuries,  or  mental  shocks  are  more 
favourable  than  those  arising  from  other  causes. 

CHOREIC  INSANITY. 

In  the  mild  cases,  which  constitute  the  majority,  the  prognosis 
is  fairly  favourable,  but  the  tendency  to  dementia  should  not  be 
overlooked.  In  the  extremely  rare  cases  of  very  acute  maniacal 
excitement  the  prognosis  is  unfavourable,  half  the  cases  proving 
rapidly  fatal  and  the  remainder  often  suffering  from  divers 
intellectual  troubles  of  variable  duration. 


174  PROGNOSIS. 

CIRCULAR  INSANITY. 

(Including  Folie  circulaire,  Folie  alternante,  and  Folie  a  double 

forme. ) 

Clouston  says  three  things  are  sure  about  the  prognosis  : — 

(1,)  Its  utter  uncertainty;  (2,)  Eecovery  cannot  be  looked  for  at 
the  climacteric  period  in  many  cases;  (.3,)  About  20  per  cent,  may 
be  expected  to  settle  down  into  a  sort  of  comfortable,  slightly  en- 
feebled condition,  in  the  senile  period  of  life.  In  another  place 
(p.  216)  Clouston  says  it  is  mostly  an  incurable  disease. 

Each  phase  may  last  a  feAV  days,  a  few  weeks,  one,  tAvo,  or  six 
months,  or  even  longer. 

Bra  says  this  form  of  insanity  inspires  no  great  hope  of 
recoveiy.  It  lasts  as  long  as  the  individual,  and  eventuates,  often 
after  a  very  long  duration,  in  dementia.  Some  individuals  retain 
considei-able  mental  lucidity  all  their  lives.  Falret  pointed  out 
the  frequent  occurrence  of  cerebral  congestion  in  these  cases. 

"Alternations  of  excitement  and  depression,  whether  amount- 
ing to  well  marked  circular  insanity  or  not,  constitute  a  bad  sign" 
(Bucknill  and  Tuke,  section  "  Prognosis  "). 

CLIMACTERIC  INSANITY. 

Of  Clouston's  cases,  53  per  cent,  recovered  ;  31  per  cent,  of  the 
men  and  57  per  cent,  of  the  women. 

Of  those  Avho  recovered,  55  per  cent,  were  discharged  within 
three  months,  65  per  cent,  within  six  months,  and  91  per  cent, 
within  twelve  months.  A  few  recovered  after  two  years  of 
treatment.  The  maniacal  and  melancholic  cases  recovered  in 
about  ecpial  proportion,  but  the  maniacal  in  shorter  time.  Only 
29  per  cent,  of  women  over  50  recovered.  From  55  to  60  the 
men  were  most  curable.  Only  3,  out  of  11  over  60,  recovered. 
Twelve  per  cent,  of  the  whole  number  of  men  suffering  from 
this  form  of  insanity  died,  but  only  9  per  cent,  of  the  women. 
Forty -seven  per  cent.,  or  excluding  cases  complicated  "vWth 
organic  brain  diseases,  59  "5  per  cent,  of  Merson's  cases  recovered 
(Bucknill  and  Tuke). 

COARSE   BRAIN  DISEASE  {Insanity  from). 
Nearly   19  per  cent,  of  Clouston's  cases  recovered  mentally. 
Organic  dementia  arising  from  cerebral  tumour  may  terminate 
fatally  in  a  month,  or  may  last  twenty  years  from  the  onset  of 
the  symptoms  (Clouston). 

CONFUSIONAL  INSANITY  (PRIMARY). 

Recovery  takes  place  in  all  except  a  small  proportion  of  cases, 
and  in  this  small  proportion  the  affection  assumes  the  chronic 
foi-m  (Spitzka). 


PROGNOSIS.  175 


CONFUSIONAL  INSANITY  (CHRONIC). 

(Chronic  Mania.) 
The  tendency  is  towards  dementia. 

CONSECUTIVE    INSANITY. 

The  cases  resembling  melancholia  and  mania,  due  to  anaemia, 
rapidly  recover.  Some  of  the  cases  resembling  persecutory 
monomania  pass  into  dementia.  Some  cases  pass  into  a 
permanent  state  of  slight  mental  weakness.  Duration  :  very 
variable. 

CYANOSIS   FROM   BRONCHITIS,  CARDIAC  DISEASE,  AND 
ASTHMA  (Insamtij  of). 
Often  passes  into  coma. 

DELIRIUM    (ACUTE). 

In  the  majority  of  cases  acute  delirium  terminates  fatally. 
Nevertheless,  if  the  disease  is  not  of  more  than  four  or  five  days' 
duration,  and  the  temperature  has  not  attained  106°  or  107°  F. 
in  the  rectum,  the  symptoms  may  improve  ;  in  which  case  the 
agitation  diminishes,  the  temperature  lowers,  the  pulse  becomes 
slower,  and  sleep  re-appears,  but  the  patients  retain  hallucinations 
and  delusions  for  a  long  time  afterwards  (Bra). 

DELUSIONAL  INSANITY. 

(Monomania,  Paranoia.) 

.  "The  prognosis  of  monomania  is  very  unfavourable.  The 
chief  feature  to  be  consulted  in  reference  thereto  is  the  mental 
power  of  the  patient.  The  more  considerable  this  is,  the  more 
likely  is  a  correction  of  the  delusive  beliefs,  the  delusive 
suspicions,  or  morbid  fears  to  take  place.  Consequently  the 
prognosis  is  best  with  those  patients  who  suffer  from  simple 
delusions  of  persecution  or  of  social  ambition,  worse  with  eroto- 
mania, and  worst  of  all  with  religious  monomania,  for  here,  as 
has  been  already  stated,  a  background  of  original  weakmindedness 
is  generally  present.  Bad  as  the  prognosis  is  in  this  form,  cases 
are  reported  where  the  hallucinations  and  delusions  disapjoeared, 
and  the  patient,  if  not  altogether  recovering,  showed  nothing- 
abnormal  beyond  an  extravagant  religious  zeal,  and  a  desire  to 
convert  mankind  to  what  he  happened  to  consider,  in  the 
excessive  egotism  of  the  fanatic,  the  right  faith "  (Spitzka, 
p.  318). 


176  PROGNOSIS. 

The  jealous  form  is  also  unfavourable  as  to  its  prognosis, 
relapses  frequently  occurring  after  apparent  recovery. 

If  not  cut  short  by  some  bodily  disease,  or  by  suicide,  mono- 
mania may  last  for  many  years,  and  then  end  in  complete 
dementia  (Clouston,  Bra,  etc.).  There  is  a  tendency  to  mental 
enfeeblement  as  time  goes  on,  and  in  most  cases  the  intensity  of 
the  conviction  of  the  delusion  and  the  aggressiveness  ynth  which 
it  is  put  forward  tend  to  diminish.  A  patient  in  Norfolk 
Asylum,  who  said  he  was  the  Lord  God  and  had  cured  the 
cattle  plague,  became  very  industrious  on  the  farm.  Another, 
who  called  himself  Lord  Nelson,  made  himself  genex'ally  iiseful 
about  the  building,  doing,  with  evident  pleasure,  a  good  deal  of 
hard  Avork. 

In  another  asylum  a  patient,  who  believed  himself  to  be  the 
rightful  Earl  of  Derby,  and  Avho  ^vas  well  versed  in  the  current 
topics  of  the  day,  and  displayed  considerable  knowledge  of  the 
various  systems  of  shorthand,  worked  contentedly  in  the  dormi- 
tories. His  delusion  had  to  be  sought,  but  when  found  was  still 
stoutly  defended. 

"  Most  monomaniacs  live  long,  all  but  the  cases  of  morbid 
suspicion,  who,  as  I  said,  mostly  die  of  phthisis"  (CloustOTi, 
p.  265). 

DEMENTIA   (TERMINAL). 

(Secondary  Dementia.) 

"  Dementia  is,  with  rare  exceptions,  incurable."  "  Fever  and 
acute  maniacal  paroxysms  have,  however,  occasionally  been  the 
means  of  restoring  to  reason  patients  apparently  sunk  in  hopeless 
dementia  "  (Bucknill  and  Tuke). 

Patients  suffering  from  severe  apathetic  terminal  dementia 
consequent  on  anergic  stupor  or  stuporous  melancholia,  as  a  rule, 
do  not  live  more  than  a  few  years.  Patients  suffering  from  the 
milder  forms  of  terminal  dementia  may,  if  well  taken  care  of, 
live  to  a  good  old  age  (Spitzka). 

DETERIORATION  (PRIMARY  MENTAL). 

If  the  first  signs  are  heeded,  comparative  mental  health  may 
be  restored  under  treatment,  "  but  if  the  exciting  causes  are  kept 
in  operation,  actual  dementia  may  be  the  result "  (Spitzka). 

DIABETIC  INSANITY. 

Prognosis  unfavourable.  The  diabetes  and  the  insanity  some- 
times alternate. 


PROGNOSIS.  177 


EPILEPTIC  INSANITY. 

Dementia  is  the  usual  termination.  The  prognosis  is,  there- 
fore, very  grave,  especially  Avhere  the  epileptic  seizures  have 
commenced  during  childhood.  When  the  attacks  of  acute 
epileptic  insanity  are  separated  by  long  intervals  the  intellectual 
faculties  are  sometimes  very  little  weakened  (Bra). 

"Epileptic  in.sanity  offers  little  hope  of  really  permanent 
recovery.  The  exceptions  are  so  few  that  it  may  be  regarded  as 
almost  incurable  "  (Bucknill  and  Tuke). 

Duration  of  each  attack  of  ante-convulsive  epileptic  insanity  : 
ordinarily,  several  hours,  occasionally,  several  days ;  of  post- 
convulsive :    usually  short,  not  extending  beyond  a  few  days. 

FOLIE  DU  DOUTE. 

The  prognosis  is  very  unfavourable  as  regards  recovery,  the 
patient  becoming  more  and  more  unsocialile  and  inclined  to  seclude 
himself.  The  morbid  ideas  and  emotions  (obsessions)  diminish  in 
number  and  extent,  but  increase  in  intensity.  The  aberration, 
although  lasting  the  lifetime  of  the  patient,  never  ends  in  true 
dementia.  In  a  few  cases  life  has  been  cut  short  by  suicide 
(Ball,  Bra).  Sometimes  there  are  long  intermissions.  Some 
cases  end  in  mental  torpor.  A  few  based  on  acquired  neurasthenia 
recover  (Krafft-Ebing). 

FOLIE     RAISONNANTE. 

Is  constitutional,  and  its  course  though  stationary  is  prolonged 
for  years  or  even  a  lifetime  (KrafFt-Ebing). 

GENERAL  PARALYSIS  OF  THE  INSANE. 

Voisin  states  that  although  the  usual  termination  of  general 
paralysis  is  death,  yet  it  may  pass  into  a  chronic  state,  and  last 
for  years,  or  it  may  terminate  in  recovery,  in  proof  of  which  he 
gives  an  account  of  thirteen  cases  drawn  from  various  sources, 
and  of  several  of  his  own,  mostly  treated  by  cold  baths. 

Death  is  caused  most  frequently  by  intercurrent  diseases  and 
complications,  such  as  pneumonia.  It  may  be  caused  by  colliqua- 
tive diarrhoea,  cystitis,  bed-sores  and  their  consequences, 
mechanical  asphyxia  by  food,  drink,  etc.,  or  by  exhaustion. 
Two-thirds  of  the  patients  are  carried  off  by  complications  of 
cerebral  origin,  evinced  by  apoplectiform  and  epileptiform 
attacks,  coma,  contractures,  etc.,  etc.  Meningeal  haemorrhages, 
uraemia,  or  oedema  of  the  ventricles  may  supervene. 

12 


178  PROGNOSIS. 

Duration. — Mickle  says  the  average  dm^ation  of  tte  disease  in 
the  soldiers  under  his  care  Avas  more  than  two  years,  but  in  the 
gentlemen  patients  at  the  same  asylum  (Bow)  it  was  very  much 
longer,  some  of  the  cases  lasting  more  than  six  or  ten  years. 

Spitzka  says,  "The  prodromal  period  may  last  only  three 
months,  usually  a  few  years,  and  in  rare  cases  nearly  a  lifetime. 
Dating  from  the  explosion  of  the  malady,  the  lethal  termination 
may  occur  in  six  months,  more  commonly  in  three  years ;  in  not 
a  small  numlDer  of  instances,  in  six,  or  ten,  or  even  more  years.'' 

According  to  Voisin,  the  duration  of  the  prodromal  period  is 
often  many  years,  six,  ten,  or  more ;  sometimes  only  three 
months. 

Savage  ("British  Medical  Journal,"  May  4,  1890)  says  the 
"  warnings  "  may  be  present  for  years,  and  that  they  are  almost 
certainly  present  for  at  least  a  year  before  even  the  specialist  can 
diagnose  general  parah'sis. 

Bucknill  and  Tuke  say  the  duration  is  generally  estimated  at 
thirteen  months,  but  think  this  aA^erage  quite  too  low.  They  say 
patients  rarely  live  more  than  three  years  after  the  development 
of  well-marked  spnptoms,  but  they  c[uote  a  case  lasting  ten  years, 
seven  of  Avhich  the  patient  was  bedridden. 

GESTATIONAL  INSANITY. 

Seventy-three  per  cent,  of  Clouston's  cases  recoA'^ered,  nearly 
all  the  recoveries  taking  place  within  .six  months  from  the  date 
of  admission.     Xone  died  of  the  disease  j^ei'  se- 

HYSTERICAL   INSANITY. 

FaA^ourable  in  acute  form,  but  relapses  are  frequent.  In 
the  chronic  form  the  ultimate  prognosis  is  unfavourable. 
Sudden  temporary  recoA^eries  are  notecl,  but  recurrence  is  very 
probable,  and  Avith  each  recurrence  deterioration  becomes  more 
marked  (Spitzka).  Chronic  hysterical  insanity  degenerates  into 
dementia  more  frequently  than  might  be  supposed,  yet  much  less 
rapidly  and  less  frequently  than  epileptic  insanity  (Bra). 

IDIOCY. 

(Including  Imbecility  and  Cretinism.) 

UnfaA'ourable  as  to  recoA^ery,  but  the  condition  may  be  much 
ameliorated  by  treatment. 

IMPULSIVE  INSANITY. 

UnfaA'ourable.  Xyin])homania,  rather  faA'Ourable  in  young 
persons,  rarely  admits  of  cure  AA'hen  it  appears  at  the  climacteric 
(Griesinger). 


PROGNOSIS.  179 


KATATONIA. 

Favourable  as  regards  life,  but  the  tendency  to  pulmonary 
tuberculosis,  in  tlie  depressed  and  atonic  stages,  must  be  kept  in 
view.  In  the  majority  of  cases  recovery  takes  place  after  one  or 
two  cycles  of  the  symptoms,  but  relapses  are  common.  The 
jDrogress  to  dementia  is  slow,  and  the  dementia  is  rarely  extreme 
(Spitzka). 

LACTATIONAL  INSANITY. 

Very  favourable  when  resulting  simply  from  the  anaemia 
induced  by  prolonged  suckling  (Bucknill  and  Tuke).  Of  Clous- 
ton's  cases,  77|  per  cent,  recovered ;  80  per  cent,  of  the 
recoveries  occurring  within  six  months,  and  all  of  them  within 
eighteen  months.     There  were  few  relapses. 

MANIA. 

Clouston  gives  the  five  usual  terminations  of  mania  as  : — 

(1,)  Complete  recovery  in  54  per  cent. 

(2,)  Partial  recovery,  leaving  mental  weakness,  eccentricity, 
change  of  character,  etc. 

(3,)  The  substitution  of  fixed  delusions  or  delusional  states  for 
the  exaltation. 

(4,)  Dementia  in  about  30  per  cent. 

(5.)  Death  in  5  per  cent. 

Clouston  includes  acute  delirium  (acute  delirious  mania)  under 
the  head  of  mania,  and  this  would  tend  to  diminish  the  per- 
centage of  recoveries  and  increase  the  percentage  of  deaths. 
Spitzka  says  various  authors  estimate  the  recoveries  at  from  60 
to  80  per  cent.,  and  that  the  latter  figure  accords  Avith  his 
experience.  Under  mania  he  does  not  include  transitory  mania 
(transitory  frenzy,  transitory  insanity),  but  this  is  a  very  rare 
and  very  curable  form. 

Convalescence  ordinarily  takes  place  slowly,  the  occurrence  of 
brief  lucid  intervals  being  the  first  indication  of  returning  health. 

Savage  "  Avould  say  that  any  case  of  acute  mania  in  Avhich  the 
excitement  was  great,  sleeplessness  well  marked,  food  either  not 
taken  at  all  or  not  assimilated,  must  be  regarded  with  danger, 
especially  in  young  and  old  cases."  The  prognosis  in  all  cases  of 
acute  mania  must  be  guarded. 

Bucknill  and  Tuke  say,  "  Acute  mania  is  in  a  large  proportion 
of  cases  recovered  from."  "  A  noisy  boisterous  mania  is  usually 
recovered  from."  They  give  the  percentage  of  recoveries  on 
admissions  (for  mania)  as  57  in  the  Pennsylvania  Hospital  for 


180  PROGNOSIS. 

the  insane,  in  thirfcy-two  years  ;  and  63"89  for  acute  mania,  and 
6-36  for  chronic,  at  the  York  Asylum,  in  tAventy-seven  years. 

Many  mild  cases  of  mania  are  treated  at  home  or  under  private 
care  successfully,  and  these  would  swell  the  percentage  of 
recoveries. 

Clouston  gives  as  indications  of  prognosis  in  mania  (including 
acute  delirium)  : — 

1st. — Favourable  :  A  sudden  onset ;  short  duration  ;  youth  of 
patient ;  no  fixed  delusions  or  delusional  conditions  ;  appetite  for 
food  not  quite  lost ;  no  positive  re"vnilsion  against  food  or  drink, 
or  perversions  of  the  food  and  drink  appetites  ;  no  indication  of  en- 
f  eeblement  of  mind  ;  no  paralysis,  or  paresis,  or  marked  affection  of 
the  pupils  ;  no  epileptic  tendenc}^ ;  no  complete  obliteration  or 
alteration  of  the  natiu^al  expression  of  the  face  or  eyes  ;  the 
instincts  of  delicacy  and  cleanliness  not  quite  lost ;  no  uncon- 
sciousness to  the  calls  of  nature ;  the  articulation  not  affected  ; 
the  disease  rising  to  an  acme  and  then  showing  slow  and  steady 
signs  of  receding  ;  no  former  attacks,  or  only  one  or  two  that 
have  recovered. 

"  Hereditary  cases  are  often  very  curable,  but  relapses  are  more 
probable." 

2nd. — Unfavourable  indications  :  A  gradual  and  slow  onset ;. 
great  length  of  duration  of  attack,  esj)ecially  after  twelve  months' 
pei'sistence  of  fixed  delusions  or  delusional  states  ;  extreme  and 
increasing  exhaustion  of  the  patient  in  spite  of  proper  treatment ; 
paralysis  of  the  trophic  power  so  that  the  nutrition  cannot  be 
restored  ;  persistent  refusal  of  food  ;  requiring  forcible  feeding ; 
extreme  failure  of  the  cardiac  action  and  circulation,  so  that  the 
extremities  are  always  blue  and  cold  ;  persistent  affections  of  the 
pupils,  especially  extreme  contraction  ;  persistently  dirty  habits; 
a  tendency  towards  dementia ;  a  tendency  towards  chronic 
mania  ;  an  utter  and  persistent  deterioration  in  the  facial  expres- 
sion, especially  if  it  be  towards  vacuity  ;  persistent  and  complete 
paralysis  or  perversion  of  the  natural  affections  and  tastes  and 
appetites  ;  many  former  attacks  ;  convulsive,  paretic,  paralytic,, 
or  inco-ordinative  symptoms  ;  such  perverted  sensations  as  cause 
patients  to  pick  the  skin,  pull  out  the  hair,  bite  off  the  nails  into 
the  quick  ;  a  restoration  of  sleep  and  bodily  nutrition  without,  in 
due  time,  an  improvement  mentally  ;  very  jjersistent  insane  mastur- 
bation ;  a  tendency  for  the  exaltation  to  pass  off  and  fixed 
delusion  to  take  its  place  ;  excitation  of  the  limbs  and  subsultus 
tendinum  ;  a  typhoicl  condition. 

Auditory  hallucinations  are  unfavourable  (Blandford). 

Extreme  and  sometimes  sudden  exhaustion  is  a  symptom 
always  to  be  feared  in  acute  mania,  but  loss  of  flesh  neecl  not 


PROGNOSIS.  181 

occasion  alarm  either  as  to  recovery  of  mind  or  body  (Bucknill 
and  Tuke). 

Duration. — Spitzka  states  that  the  average  duration  of  typical 
mania  is  about  five  months,  including  an  initial  stage  of  depression 
of  six  weeks,  a  maniacal  period  of  about  three  months,  and  a  period 
of  convalescence  of  about  a  fortnight ;  but  some  intense  cases 
may  last  only  a  few  weeks,  Avhilst  some  mild  ones  may  last  a 
year  or  more.  The  duration  of  transitory  mania  varies  from  an 
hour  up  to  a  few  days  (Clouston). 

Of  acute  mania  Clouston  says  60  per  cent,  recover,  Ih  per 
cent,  die  (he  includes  acute  delirium),  and  32|  per  cent,  become 
demented,  or  pass  into  chronic  mania. 

Of  the  deaths  from  mania  generally,  Clouston  gives  5  per 
cent,  as  the  average  on  the  admissions,  the  immediate  cause  of 
death  being  maniacal  exhaustion,  or  some  cause  directly  traceable 
to  the  disease.  Bucknill  and  Tuke  give  4  per  cent,  and 
Spitzka  gives  2  to  5  per  cent.  The  three  first  mentioned 
evidently  include  acute  delirium,  and  Spitzka,  puerperal  insanity 
(maniacal  form).  Excluding  these  diseases,  and  including  many . 
mild  cases  treated  at  home,  the  mortality  would  be  somewhat  lower. 

MASTURBATIONAL   INSANITY. 

Of  Clouston's  cases,  34-78  per  cent.  (16  out  of  46)  recovered, 
and  a  somewhat  larger  percentage  went  home  more  or  less 
improved,  the  remainder  being  "  hopeless,  incurable,  and  de- 
graded." He  states  that  there  is  no  special  risk  of  relapse,  and 
no  tendency  to  any  special  form  of  nervousness  of  lifelong 
duration.     Spitzka  says  the  prognosis  is  bad. 

MELANCHOLIA. 

Clouston  gives  54  as  the  percentage  of  recoveries  on  admission, 
About  one-third  of  the  cases  were  relapses.  He  says  the  recovery 
rate  would  no  doubt  be  much  greater  if  the  milder  cases  treated 
at  home  were  included.  He  says  simple  melancholia  is  in  most 
cases  curable,  except  in  very  advanced  life  or  when  it  accompanies 
organic  brain  disease.  Clouston's  experience  is  that  hypochon- 
driacal melancholia,  "when  it  occurs  at  the  more  advanced  ages, 
is  apt  to  be  permanent,  or  the  prelude  to  senile  dementia."  He 
states  that  about  50  per  cent,  of  the  cases  of  melancholic  stupor 
recover. 

Maudsley  says  melancholia  is  the  most  curable  of  the  forms  of 
mental  disease,  acute  mania  coming  next  in  order. 

Spitzka  states  that  about  six  cases  of  melancholia  out  of  ten 
admissions  recover  completely,  females  recovering  in  greater 
proportion  than  males. 


182  PROGNOSIS. 

He  says  that  the  lighter  forms  are  very  common  in  general 
practice,  and  are  often  treated  as  neui'asthenia  and  dyspepsia,  and 
frequently  cui-ed.  Apart  from  the  tendency  to  suicide  and  the 
liability  to  recxu",  the  prognosis  of  melancholia  sine  delirio  is 
always  favourable.  Next  come  the  typical  and  agitated  forms, 
80  per  cent,  of  these  patients  recovei'ing  under  early  and  proper 
treatment.  "With  stupid  or  atonic  melancholia  the  outlook  is 
bad." 

Bucknill  and  Tuke  are  of  opinion  that  "Acute  melancholia,  if 
cases  which  never  reach  an  asylum  are  included,  is  at  least  as 
frequently  cured  (as  acute  mania),  but  certainly  in  asylum 
experience  comes  next  in  order."  And  that  "  Simple  depression 
of  mind  is  not  unfavoiu^able  except  in  the  decline  of  life." 

Duration. — Spitzka  places  the  average  duration  of  melancholia 
at  from  three  to  eight  months. 

Clouston  states  that  50  per  cent,  of  his  recoveries  occurred  under 
three  months,  75  per  cent,  under  six,  and  87  per  cent,  under 
twelve  months.  A  few  patients  make  sudden  recoveries  in  a 
few^  days. 

Clouston  gives  as  favourable  signs  or  conditions :  Youth, 
sudden  onset,  a  removable  cause,  want  of  fixed  delusion,  absence 
of  hallucinations  of  hearing,  taste,  or  smell ;  no  visceral  delusions  ; 
no  strongly  impulsive  or  epileptiform  symptoms  ;  no  picking  of 
the  skin,  or  pulling  out  the  hair,  or  such  trophic  symptoms  ;  no 
long  continued  loss  of  body  weight  in  spite  of  treatment ;  no 
long  continued  inattention  to  the  calls  of  nature,  and  no  dirty 
habits. 

Bad  signs  :  Slow  gradual  onset ;  fixed  delusions,  visceral  or 
organic ;  gradual  decay  of  bodily  vigour ;  persistent  loss  of 
ntitritive  energy  and  l^ody  "weight ;  convulsive  attacks  and  motor 
affections  generally,  not  ideomotor ;  persistent  hallucinations, 
especially  of  hearing,  smell,  and  feeling ;  picking  the  skin  or 
hair  ;  persistent  refusal  of  food  ;  an  unalterable  fixity  of  expres- 
sion of  emotional  depression  in  face,  or  persistence  of  muscular 
expression  of  mental  pain  ('wringing  hands,  groaning,  etc.) ; 
persistent  suicidal  tendency  of  much  intensity  ;  arterial  degene- 
ration ;  senile  degeneration  of  brain  ;  no  natural  fatigue  following 
persistent  motor  efforts  in  walking,  standing,  etc.  ;  a  mental 
enfeeblement  like  dementia.  But  the  prognosis  should  be  guarded 
in  almost  eA^ery  case. 

The  prognosis  is  more  favourable  according  as  there  is  less 
stupor,  less  nutritive  disttirbance,  more  variation  in  the  symptoms 
from  day  to  day,  and  with  youth  and  the  female  sex.  It  is  of 
speciall}^  good  import  -when  the  patient's  condition  shows  a 
marked  improvement  from  evening  to  evening  (Spitzka). 


PROGNOSIS.  183 

Termination. — The  tendency  to  dementia  is  much  less  marked 
than  in  mania  (Bucknill  and  Tuke). 

Clouston  says  a  few  (mostly  middle-aged  or  old  people)  end  in 
chronic  melancholia  and  a  few  pass  into  dementia,  which  is  never 
so  complete  a  mental  enfeeblement  as  when  it  follows  mania.  He 
says  many  of  the  cases  pass  into  mania. 

Spitzka  states  that  the  cases  which  do  not  recover  or  die  pass 
into  apathetic  terminal  dementia  (a  common  sequel  of  melan- 
cholia attonita),  or  into  chronic  delusional  insanity  with  deteriora- 
tion (chronic  confusional  insanity),  an  occasional  sequel  of  the 
typical,  and  a  more  frequent  one  of  the  agitated  forms. 

METASTATIC  INSANITY. 

Recovery  often  follows  re-appearance  of  the  original  disease. 

Prognosis  favourable,  "  when  the  derangement  has  followed 
the  suppression  of  an  eruption  or  an  accustomed  discharge  " 
(Maudsley,  "The  Physiology  and  Pathology  of  Mind,"  p.  489). 

MORAL  INSANITY. 

Prognosis  unfavourable  (Bucknill  and  Tuke). 

MYXEDEMA  (Insanity  of). 

Unfavourable  (Savage).  The  tendency  is  to  pass  slowly  and 
steadily  into  dementia.  The  duration  of  life  depends  upon  the 
bodily  condition  and  upon  the  secondary  degenerations  which 
may  occur.  Presence  of  albumen  unfavourable  to  longe^aty 
(Savage). 

NEURASTHENIA  AND  NEURASTHENIC  INSANITY. 

Neurasthenia. — Favourable  when  acquired  (post-febrile,  post- 
puerperal,  etc.);  unfavourable  when  constitutional  (commence- 
ment at  puberty,  traces  in  early  childhood). 

Neurasthenic  Insanity. — Favourable  in  the  psychoneurotic 
group  ;  unfavourable  in  the  degenerative,  except  in  the  rare  cases 
founded  on  acquired  neurasthenia. 

OYARIAN  OR  «  OLD  MAID'S  "  INSANITY. 

None  of  Clouston's  cases  recovered,  but  in  two  out  of  ten,  as 
they  passed  into  the  senile  period,  the  delusion  became  so  theoret- 
ical that  they  almost  ceased  to  allude  to  it. 

OXALURIA  AND  PHOSPHATURIA  {Insaniti/  of). 
Few  require  asylum  treatment.     The  nervous  symptoms  dis- 
appear under  the  treatment  that  cures  the  oxaluria  (Clouston). 


184  PROGNOSIS. 


PARALYSIS  AGITANS  {Insanity  of). 
As  the  sensory   troubles   become   increased  or  disappear,   so 
do  the  mental. 

PARTIAL  EMOTIONAL  ABERRATION. 

(Pathophobia,  Kovalewsky ;  Agorajjhobia,  Claustrophobia, 
Mysophobia,  etc.) 

These  patients  seldom  or  neA^er  find  their  way  into  asylums. 
Prognosis  similar  to  that  oi  folie  du  chute  (q  v.). 
According  to  Kovalewsky  the  order  of  evolution  is  :    (1,)  Neu- 
rasthenia ;  (2,)  Pathophobia;  (3,)  Folie  du  doute. 

PARTIAL  EXALTATION,  OR  AMENOMANIA. 

Prognosis  more  favourable  than  in  true  ambitious  or  religious 
delusional  insanity. 

PELLAGROUS  INSANITY. 

Passes  on  to  chronic  dementia  (Sibbald).  Pellagra  itself,  if 
treated  early,  is  curable  in  the  proportion  of  78  per  cent. 
(Erasmus  Wilson). 

Unfavourable  (Bucknill  and  Tuke),  yet  has  been  cured  after 
lasting  some  years.  This  applies  to  pellagrous  insanity  as  well  as 
pellagra. 

Duration  of  majority  of  cases  of  pellagra,  about  three  years, 
but  may  be  from  one  to  fifty  or  sixty  years  (Bucknill  and  Tuke, 
Wilson,  etc.). 

PERIODICAL  INSANITY. 

UnfaA^ourable.  "  Shares  the  bad  prognosis  as  to  recovery  with 
other  degenerative  disorders,  such  as  monomania  (paranoia) 
and  epileptic  insanit}^  "  (Spitzka,  p  267). 

PHTHISICAL     INSANITY. 

Recovery  rate  30  per  cent.  (Clouston). 

PODAGROUS  OR  GOUTY  INSANITY. 

In  the  mild  form,  with  matutinal  dread,  treatment  is  markedly 
successful  (Bucknill  and  Tuke). 

POST-CONNUBIAL  INSANITY. 

Curable  and  not  prolonged  (Clouston). 

PUBESCENT  INSANITY. 

Spitzka  says  the  prognosis  is  on  the  whole  exceedingly  un- 
favourable,   and   that    the    course   is    protracted.     Imperfectly 


PROGNOSIS.  185 

develoijecl  cases  which  appear  to  be  only  a  pathological  intensifi- 
cation or  undue  prolongation  of  the  ordinary  pubescent  state' 
present  better  prospects.  The  period  he  includes  is  from  the 
fifteenth  to  the  twenty-second  year.  The  habit  of  masturbation 
increases  the  gi-avity  of  the  prognosis. 

PUERPERAL  INSANITY. 

Of  Clouston's  cases,  75  per  cent,  recovered,  more  than  half  of 
the  recoveries  occurring  within  three  months  and  nine-tenths 
within  six  months. 

Of  Bevan  Lewis's  cases,  four-fifths  recovered,  more  than  one 
half  of  the  recoveries  having  occurred  by  the  fifth  month,  and 
nearly  nine-tenths  of  them  by  the  ninth  month  from  the  commence- 
ment of  the  insanity. 

"  Very  favourable  unless  it  assumes  an  inflammatorj^  or  typhoid 
type "  (Bucknill  and  Tuke).  According  to  Savage's  statistics, 
quoted  by  Bucknill  and  Tuke,  the  third  month  showed  the 
majority  of  recoveries  from  puerperal  mania  and  the  sixth  from 
puerperal  melancholia,  the  average  duration  of  the  latter  being 
longer  than  that  of  the  former.  Bra  says  the  prognosis  is  more 
favoiurable  in  the  maniacal  than  in  the  melancholic  form.  Bevan 
LcAvis  says  the  prognosis  is  influenced  more  especially  by  the 
duration  before  treatment  and  by  the  age  of  the  patient ;  if  the 
former  be  less  than  a  week  and  the  latter  under  thirty  years,  it  is 
favourable.  In  spite  of  the  generally  favourable  prognosis 
Savage  advises  caution,  OA^ang  to  the  number  of  deaths  and  the 
frequency  of  cases  passing  into  chronic  insanity  or  weakminded- 
ness. 

Bevan  Le^vis  and  Clouston  give  their  mortality  as  8"5  per  cent, 
and  8'3  per  cent,  respectively,  four-fifths  of  the  latter  occurring 
within  one  month,  and  all  within  two  months. 

RHEUMATIC  INSANITY. 

The  severe  or  supra-acute  form  of  cerebral  rheumatism  is  brief 
and  fatal.  The  prognosis  is  less  grave  in  the  acute  or  less  severe 
form,  recovery  sometimes  taking  place  in  the  worst  looking  cases. 
In  some  cases  the  patient  passes  into  a  state  of  chronic  insanity. 
The  prognosis  should  always  be  guarded,  and  guided  by  the 
thermometric  indications. 

In  the  vesanic  form,  or  rheumatic  insanit}:^  (properly  so  called), 
recovery  takes  place  in  the  majority  of  cases.  It  is  gradual,  and 
may  be  complete,  but  more  commonly  some  weakness  of  mind 
remains.  If  rheumatic  insanity  continues  more  than  three  or 
four  months  dementia  supervenes  (Bra). 


186  PEOGNOSIS. 

SENILE    INSANITY. 

Of  Clouston's  cases,  admitted  dimng  a  period  of  nine  years,  35 
per  cent,  recovered,  half  of  them  ■\%athin  three  months  of 
admission  and  79  per  cent,  of  them  mthin  six  months  ;  .33  per 
cent,  of  the  cases  died,  20  per  cent,  of  the  deaths  making  seven 
per  cent,  of  the  whole  of  the  cases  occurring  within  the  first 
month,  a  month  in  which  there  is  great  danger  of  death  in  senile 
insanity.  More  than  half  the  deaths  occuiTed  within  the  first 
six  months  of  residence.  Thirty-three  per  cent,  of  the  cases  were 
of  senile  melancholia,  30  per  cent,  of  typical  senile  dementia 
(incurable),  and  the  remainder  were  cases  of  senile  mania.  Only 
30  per  cent,  of  the  melancholic  cases  recovered,  but  the  recoveries 
were  as  a  rule  better  than  in  the  maniacal  cases.  Rather  more 
than  half  the  whole  recoveries  were  mere  gradual  passings  into 
manageable  senility. 

Bevan  Le^vis  states  that  simple  senile  melancholia  is  a  fairly 
recoA'erable  form  of  alienation,  but  the  strongly  marked  suicidal 
tendency  must  be  kept  in  view.  He  says  cases  of  senile  mania, 
though  often  passing  into  permanent  dementia,  may  completely 
recover,  A\ath  scarcely  any  abnormal  mental  weakness  remaining. 

SOMNAMBULISM  {Pseudo-Insanity  of). 
Few  sleep-walkers  ever  become  actually  insane  (Clouston). 

STUPOR,   ANERGIC. 

(Acute  Dementia.) 

Typical  anergic  stupor  in  young  persons  is  very  curable 
(Clouston).  Spitzka  says  the  prognosis  is  highly  favourable, 
probably  90  per  cent,  recovering.  Youth  and  sudden  onset,  as 
from  fright  or  profuse  haemorrhage,  favour  rapid  recovery ; 
masturbation  imfavourable.  Uncured  cases  sink  into  apathetic 
dementia  or  die  of  pulmonary  disease. 

Duration. — May  be  only  a  few  weeks.  Usually  from  one  to 
three  months  (Spitzka). 

SYPHILITIC   INSANITY. 

The  cephalalgic  form  of  cerebral  syphilis  is  favourable,  inas- 
much as  it  arouses  attention  and  leads  to  treatment. 

The  epileptic  or  convulsive  form  is,  according  to  Fournier,  one 
of  the  most  favoui-able,  for  the  same  reasons.  It  yields  readily 
to  early  specific  treatment. 

The  congestive  form  is  much  less  favourable.  It  is  insidious, 
and  leads  to  apoplectic  and  paralytic  attacks,  to  inLellectual 
disturbances,  etc. 


PROGNOSIS.  187 

The  paralytic  form  indicates  disorganisation,  often  irreparable, 
of  the  nervous  centres. 

Of  the  mental  form  (syphilitic  insanity  j)roperly  so  called)  the 
prognosis  is  unfavourable  when  it  assumes  from  the  first  the 
character  of  slow  progressive  mental  weakness.  When  a  state  of 
complete  hebetude  is  arrived  at,  the  prognosis  is  hopeless. 

Syphilitic  pseudo-general  paralysis  is,  of  all  forms  of  cerebral 
syphilis,  the  most  unfavourable  as  to  its  prognosis.  It  is  often 
refractory  to  treatment.  Speaking  generally,  the  intellectual 
disturbances  in  cerebral  syphilis  have  a  marked  tendency  to 
continuous  aggravation  and  to  terminate  after  a  few  months,  or 
two  or  three  years,  in  confirmed  dementia. 

Sometimes  death  supervenes  rapidly,  or  sudden  coma  sets  in, 
or  a  maniacal  outburst  takes  place,  or  a  hemiplegic  attack  occurs, 
etc.,  etc. 

The  intellectual  troubles  are  less  influenced  by  specific  treat- 
ment than  the  other  symptoms  of  cerebral  syphilis.  The 
prognosis  is,  therefore,  always  serious  (Bra). 

Hughlings  Jackson,  speaking  of  syphilitic  cerebral  neoplasms, 
calls  attention  to  the  fact  that  although  the  growths  themselves 
may  1)e  removed  by  specific  treatment,  their  destructive  eff"ects  on 
the  surrounding  brain  tissue  are  not  amenable  to  any  medication. 

TOXIC  INSANITY. 

Acute  Alcoholic  Insanity. — Unless  the  brain  has  been  weakened 
by  repeated  attacks,  both  forms  (maniacal  and  melancholic)  are 
curable,  and  generally  of  short  duration  (Sibbald). 

Deliri'nm  Tremens. — If  the  temperature  taken  in  the  rectum, 
after  oscillating  two  or  three  days  round  102°1  F.,  rises  to  TOSS'S, 
the  prognosis  is  unfavourable,  and  becomes  more  so  if  the 
temperature  rises  still  further,  or  even  persists  at  that  elevation. 
When,  on  the  contrary,  the  temperature  rises  somewhat  rapidly 
to  102°1,  or  even  104°,  and  falls  again  at  the  end  of  24  or  48 
horus,  the  prognosis  is  favourable.  In  mild  cases  the  tempera- 
ture may  rise  to  101°  F.,  or  101°4  F.,  but  in  such  cases  it 
sinks  rapidly  during  temporary  quietude  and  oscillates  about 
100°2  F.  The  extent  and  intensity  of  the  tremor,  the  muscular 
weakness,  the  degree  of  chronicity  of  the  intoxication,  and,  in 
the  complicating  form,  the  intercurrent  disease  have  all  to  be 
considered.  If  the  tremor  is  local,  transitory,  and  slight,  the 
case  is  mild  ;  if  it  is  intense,  general,  and  persistent,  continuing 
during  sleep,  and  accompanied  by  shudderings,  shocks,  and 
undulations,  nervous  exhaustion  sets  in  on  the  second  or  third 
day  (Magnan).  In  the  majority  of  cases  of  delirium  tremens 
the   patient  recovers.       Eecovery   may   be   delayed   for   eight, 


188  PROGNOSIS. 

fifteen,  or  more  days,  and  is  announced  by  the  return  of  sleep 
and  the  amelioration  of  all  the  symptoms.  Yet  the  prognosis  is 
always  grave  on  account  of  the  tendency  to  relapse  (Bra).  After 
two  or  three  attacks  the  mind  is  sometimes  hopelessly  weakened 
^Wth  blunted  moral  feeling  and  considerable  cunning  (Maudsley). 

Chronic  Alcoholic  Inmnitij. — "The  prognosis  of  this  form  of 
insanity  is  very  unfavourable,  as  there  is  a  pronounced  tendency 
to  dementia.  Complete  cures  are  rare,  and  if  the  affection  has 
lasted  any  length  of  time,  impossible.  The  higher  the  mental 
status  of  the  patient  the  better  are  his  chances  "  (Sjoitzka). 

As  alcoholic  intoxication  advances,  dementia,  partial  paralysis, 
and,  in  some  cases,  general  paralysis,  supervene  (Magnan). 

Insanity  from  Opium. — "It  may  be  cured,  or,  at  least,  the 
attack  may  be  got  over,  by  the  total  removal  of  the  drug"  (Savage). 
The  prognosis  (ultimate)  is  unfavourably  influenced  by  the 
difficulty  of  breaking  off  the  opium  crave.  Savage  considers  the 
opium  crave  the  greatest  of  the  craves,  and  the  chloral  crave 
the  least,  or  among  the  least.  Patients  for  the  most  part  recover 
from  the  insanity  set  up  by  cannahis  iiulica  (Blandford). 

Saturnine  Insanity. — Favourable  in  satm^nine  mania  and 
melancholia  when  the  affection  has  not  lasted  more  than  four  or 
five  weeks.  Kecovery  is  announced  by  the  return  of  sleep  (Bra). 
The  com-ulsive  form  most  frequently  terminates  in  death.  In 
satui'nine  pseudo-general  paralysis  the  tendency  to  amelioration 
is  soon  seen  and  sometimes  very  soon  (Bra). 

TRAUMATIC  INSANITY. 

Remarkable  for  its  long  duration.  "  As  a  rule  progressive 
detei'ioration  sets  in,  and  dementia  terminates  the  history  of  the 
case  "  (Spitzka). 

In  cases  complicated  \nih.  alcohol  the  mental  symptoms 
are  aggravated  and  there  is  a  still  stronger  tendency  to  in- 
curability (Clouston).  Clouston  admitted  twelve  cases  in  nine 
years,  and  he  describes  two  cases  which  recovered,  one  after  an 
operation,  by  which  a  depressed  portion  of  the  skull  Avas  removed. 
Only  one  of  these  cases  belongs  to  the  twelve  admissions  above 
mentioned. 

UTERINE  OR  AMENORRH(EAL  INSANITY. 

The  melancholic  cases  usually  recover  when  the  general  health 
is  restored  and  menstruation  re-established  (Clouston). 

The  maniacal  cases  do  not  show  the  same  tendency  to  recover 
coincidently  mth  the  restoration  of  menstruation  (Clouston). 

YOUNG  CHILDREN  {Delirium  of). 
Favourable  under  treatment  (Clouston). 


PATHOLOGY.  189 


CHAPTER   VII. 

PATHOLOGICAL    ANATOMY,    PATHOLOGY    AND 
PATHOGENESIS. 

MOEBID    ANATOIVIY. 

A.— GENERAL. 

I. — Macros  copicAL. 

(«,)  The  Cranium  may  be  abnormally  large  or  small,  or  it 
may  be  malformed.  The  cranial  bones  may  be  increased  or 
diminished  in  thickness  or  in  density,  or  in  both. 

(b,)  The  Dura  Mater  may  be  adherent  to  the  cranial  bones. 
It  may  be  redder  than  usual  from  increased  vascularity.  It  may 
be  abnormally  thick,  excessively  tense  or  very  lax  (Griesinger). 

(c,)  The  Arachnoid. — Opacity  of  the  arachnoid  is  frequently 
met  "v^ath  in  all  forms  of  insanity,  but  is  also  seen  in  elderly  sane 
persons.  Opacity  \Wth  thickening  is  especially  frequent  in 
general  paralysis.  This  condition  of  the  arachnoid  with  increase 
of  the  pacchionian  gi-anulations  is  found  in  drunkards  and  other 
persons  subject  to  habitual  cerebral  congestion  during  life. 

Osseous  concretions  may  be  found,  or  abnormal  adhesions  to 
pia  and  cortex.  Frequently  there  are  fine  granulations  on  the 
external  surface. 

There  may  be  ecchymoses.  There  may  be  inflammation  of  the 
parietal  layei^,  pacchymeningitis  interna,  accompanied  by  firm 
pseudo-membranous  or  thin,  quasi-gelatinous,  structures.  The 
serous  fluid  is  frequently  increased  in  quantity  (Griesinger). 

JDurhcematomata  or  arachnoid  cysts  are  frequently  found  in  the 
sac  of  the  arachnoid,  especially  in  general  paralysis.  They  are 
also  found  after  terminal  dementia,  chronic  mania,  and  acute 
mania.  Griesinger  considers  them  to  be  of  special  importance, 
and  speaks  of  them  as  spontaneous  hsemorrhages.  When  the  ex- 
travasation is  considerable,  the  fluid  at  first  thick  and  dark  bro^^oi 
becomes  clear  ^Yith.  time.  When  the  amount  is  small,  the  watery 
portion  is  absorbed,  leaving  a  layer  of  fibrine  at  first  bro'wn,  then 
yellow,  then  almost  colourless.  They  should  not  be  confounded 
with  sub-arachnoid  serous  effusions,  Avhich,  according  to  Griesinger, 
have  no  special  significance. 


190  PATHOLOGY. 

The  large  ones  cause  compression,  atrophy,  and  increased  con- 
sistence of  the  hemisphere  with  infiltration  of  the  meninges. 

Hremorrhage  beneath  the  arachnoid  is  much  less  frequent  and 
has  no  special  significance. 

{d,)  The  Pia  Mater. — There  may  be  active  liypenemia  appear- 
ing as  a  very  intense  uniform  injection  of  the  smallest  vessels 
with  small  stellate  ecchymoses.  This  condition  is  found  after  acute 
delirium  (acute  delirious  mania)  and  violent  mania  (Griesinger). 

There  is  also  a  form  of  congestion  more  connected  "nath  the  large 
veins  and  due  to  varicosities,  etc.  This  form  (hypersemia  "ex 
vacuo  ")  is  chronic  in  its  course  and  frec[uently  associated  with 
cerebral  atrophy.  It  may  also  be  the  result  of  mechanical  venous 
stases,  and  then  always  exerts  an  influence  upon  the  form  of  the 
disease. 

There  may  be  ancemia  of  the  pia  mater,  causing  it  to  be 
remarkably  pale.  When  chronic,  it  gives  rise  mostly  to  states 
of  mental  Aveakness  and  dementia  (Griesinger). 

As  the  result  of  chronic  hyperemia  "  ex  vacuo,"  there  may  be 
opacity,  thickness,  and  oedema  of  the  pia  mater.  This  oedema  is 
frequent,  especially  after  the  secondary  forms,  mth  mental 
weakness  well  marked. 

There  may  be  inflariinuition  of  the  pia,  producing  in  combination 
with  cortical  inflammation  adhesion  of  the  membranes  to  each 
other  and  the  cerebral  cortex.  This  adhesion,  the  result  of 
meningo-cerebritis,  particularly  affects  the  convexity  and  the 
contiguous  internal  surfaces  of  the  hemis23heres,  the  cornu 
ammonis  being  also  often  implicated.  It  occurs  most  frequently 
in  general  paralysis,  and  is  the  most  constant  lesion  in  that 
disease.  It  may  occur  in  simple  chronic  insanity,  especially  in 
terminal  dementia ;  and  in  chronic,  alcoholic,  and  epileptic 
insanity  (Griesinger). 

It  may  occur  in  senile  mania,  and  is  frequently  met  with 
in  traumatic  insanity  (Lewis). 

{e,)  The  Cerebral  Substance  : — («,)  Colour. — The  cortex 
may  be  markedly  pale,  as  in  aneemic  insanity,  phthisical  insanity, 
and  insanity  after  haemorrhages,  or  in  other  forms  of  insanity 
accompanied  by  general  anaemia.  Sometimes  in  states  of  mental 
weakness  and  dementia  without  general  aneemia  (Griesinger). 

The  cortex  may  present  violet  or  wine  coloured  softenings 
in  acute  mania  Avhen  death  has  occurred  suddenly  during 
excitement.  Pinel  found  redness  of  the  middle  layer  in  mania  ; 
Baillarger  of  the  three  gray  strata.  Most  frequently  the 
inflammation  is  of  the  most  superficial  layers  ;  when  the  adherent 
pia  is  detached  an  eroded  surface  is  left.  This  is  the  condition 
generally  found  after  death  from  general  paralysis. 


PATHOLOGY.  191 

In  acute  delirium  there  is  redness  of  the  cerebral  cortex. 

The  medullary  substance  may  be  abnormally  pale,  may  be 
mottled  with  red,  or  rose,  violet  or  lilac  colour,  or  on  a  hardened 
section  may  present  a  number  of  fine  white  points  (miliary  sclerosis, 
colloid  bodies).  Miliary  sclerosis,  described  by  Batty  Tuke,  is 
found  in  cases  of  chronic  insanity.  Sjoitzka  says  the  so-called 
miliary  sclerosis  can  be  produced  by  the  action  of  alcohol,  the 
colloid  bodies  being  tiny  aggi'egations  of  leucin.  The  medullary 
substance  may  also  be  a  dirty  white  colour,  blue  or  gray, 
Avithout  puncta  vasculosa.  There  may  be  hgemorrhagic  foci 
in  the  ganglia,  white  substance  or  cortex.  There  may  be  dark 
spots  with  softening  and  loss  of  substance  consecjuent  on  hsemor- 
rhagic  foci.  There  may  be  patches  of  yellow  softening  in  the 
ganglia  or  cortex,  or  of  white  softening  in  the  medullary 
substance.  There  may  be  widely  spread  but  superficial  yellow 
softening  of  many  convolutions  presenting  itself,  without  loss  of 
substance,  on  removing  the  soft  membranes.  Occasionally 
haemorrhage  may  show  darkly  through  the  basilar  cerebral  tissue. 

(/3,)  Size  and  Form. — Cerebral  atrophy  is  frequently  met  with 
(Grriesinger). 

It  is  sometimes  convolutional,  sometimes  general.  It  may 
be  primary  (senile  or  premature  marasmus  of  the  brain) ;  or 
it  may  be  secondary  to  inflammation,  hypersemia,  or  compression 
(Griesinger). 

In  the  chronic  forms  of  insanity  atrophy  is  most  frequently 
found  in  the  fronto-parietal  regions,  especially  in  the  frontal  lobes 
(Lewis). 

Atrophy  is  very  common  in  general  paralysis,  terminal 
dementia,  and  chronic  alcoholism.  It  is  rare  in  recent  insanity 
(Griesinger). 

The  cornu  ammonis  is  atrophied  in  50  per  cent,  of  the  epileptic 
insane  (Meynert). 

The  brain  is  frequently  very  small  in  idiocy.  In  paralytic 
idiocy  one  cerebral  hemisphere  is  generally  larger  than  the  other, 
the  opposite  half  of  the  cerebellum  being  then  frequently  smaller 
than  its  fellow,  and  the  olivary  body  on  the  side  of  the  larger 
cerebral  hemisphere  of  greater  magnitude  than  the  one  on  the 
side  of  the  larger  cerebellar  hemisphere  (Meynert,  Schroeder  van 
der  Kolk,  Fritsch,  etc.). 

Cases  illustrating  crossed  atrophy  of  the  cerebrum  and  cere- 
bellum have  been  reported  by  me  in  the  "  Brit.  Med.  Jour." 
and  the  "Jour,  of  Ment.  Science,"  1882. 

The  brain  may  be  abnormally  large  in  idiocy,  either  from 
hypertrophy  or  from  dilatation  of  the  ventricles  by  fluid  ;  or  one 
hemisphere  may  be  abnormally  large   with   dilated   ventricles, 


192  PATHOLOGY. 

whilst  the  othei'  is  excavated  or  fragmentary,  being  in  great 
part  replaced  by  a  serous  cyst  (porencephalus).  Such  a  case  was 
reported  by  me  in  the  "  Brit.  Med.  Jom\,"  1882.  In  insanity  from 
coarse  brain  disease  there  may  be  more  or  less  extensive  poren- 
cephalous  excavations  of  the  cortex  or  cerebral  ganglia,  or  both  ; 
or  tumours  of  the  substance  may  protrude,  or  those  of  bone  or 
membrane  leave  indentations  in  the  brain  substance. 

According  to  Buchstab,  the  frontal  lobes  are  normallj-  larger  in 
the  male  than  the  female,  and  the  occipital  larger  in  the  latter 
than  in  the  former  ("Jour.  Xerv.  and  Ment.  Dis."). 

(7.)  Consistence. — -There  may  be  softening,  general  or  local, 
resulting  from  inflammation  or  oedema  in  the  former  case,  and 
from  thrombosis  or  embolism  in  the  latter. 

General  softening  is  found  in  general  paralysis,  and  is  especially 
marked  in  the  superficial  cortical  layer  of  the  convexity  of  the 
hemisphere.  It  is  also  found  in  chronic  insanity  and  in  senile 
insanity.  Local  softenings  are  also  found  in  these  forms  and 
in  insanity  from  coarse  brain  disease. 

The  cortical  area  most  prone  to  thrombotic  and  embolic 
softening  is  that  supplied  by  the  parieto-sphenoidal  branch  of  the 
middle  cerebral  or  Sylvian  artery ;  the  left  side  being  more  liable 
to  be  affected  than  the  right.  Xext  in  frequency  comes  the  area 
supplied  by  the  occipital  branch  of  the  posterior  cerebral. 

Localised  softenings  may  also  be  due  to  fatty  degeneration 
(Bucknill  and  Tuke). 

There  may  be  induration,  general  or  local,  the  former  in  chronic 
insanity,  the  latter  in  idiocy. 

(0,)  Specific  Gravity. — The  conditions  which  favour  high  sp.  gr. 
are  congestion  and  induration ;  those  which  faA'our  a  Ioav  one, 
oedema  and  fatty  degeneration.  A  watery  or  cedematous  condition 
of  the  brain  is  frequently  met  "\\'ith  in  dementia  and  chronic 
insanity  generally,  and  in  siich  cases  the  sp.  gT.  is  low.  It  is  low 
in  the  softened  condition  of  circumsci"ibed  portions,  which  the 
microscope  shows  to  be  one  form  of  fatty  degeneration  (Bucknill 
and  Tuke). 

The  same  authors  quote  a  case  (p.  589)  in  which  the  sp.  gr.  of 
the  cerebrum  generally  was  1041,  that  of  the  softened  part  1035. 
According  to  them  the  normal  average  sp.  gT.  of  the  cerebellum 
is  greater  than  that  of  the  cerebrum,  and  that  of  the  cerebral 
white  substance  greater  than  that  of  the  gray. 

Thudichum  gives  the  mean  sp.  gr.  of  the  gray  tissue  as  1032, 
of  the  Avhite  as  1011,  of  the  whole  brain  as  1037. 

(e,)  IVeight. — Griesinger  agrees  ^^ath  Parchappe  that  a  diminu- 
tion of  brain  weight  takes  place  in  insanity  generally,  and 
especially  in  chronic  insanity.     In  some  cases  of  insanity  from 


PATHOLOGY.  193 

coarse  brain  disease  the  weight  is  mucli  diminished  from  local  loss 
of  cerebral  substance.  In  general  paralysis  there  is  a  diminution 
in  weight  varying  from  about  one  to  about  five  ounces  (Mickle). 

In  senile  insanity  the  weight  is  also  considerably  diminished. 

Luys  ("L'Encephale  ")  says  that  whilst  in  healthy  persons  the 
left  cerebral  hemisj)here  is  generally  heavier  than  the  right, 
the  reverse  holds  good  in  cases  of  chronic  insanity. 

BischofF  has  given  the  average  normal  weight  of  the  brain  as 
1362  grammes  in  the  male,  and  1219  in  the  female  ;  E.  Boyd  as 
1325  and  1183  respectively  ("  Allg.  Zeit.  f.  Psych."). 

(/,)  The  Ventricles. — They  may  be  dilated  (chronic  hydro- 
cephalus). Their  surfaces  may  be  granular  as  in  general  paralysis 
and  hydrocephalus. 

(g,)  The  Cerebellum. — Diminished  in  consistence  but  not  in 
weight ;  hyperasmic  ;  membranes  thickened  and  often  adherent  in 
general  paralysis  (Voisin,  Mickle) ;  asymmetrical,  atrophic,  and 
occasionally  absent  in  idiocy.  Sometimes  softened  locally  or 
atrophied  in  insanity  from  coarse  brain  disease.  Occasionally 
defectively  developed  in  epileptic  insanity. 

II. — Microscopical. 

For  microscopical  morbid  anatomy  vide  infra  (special  morbid 
anatomy). 

B.— SPECIAL. 

Choreic  Insanity. — Small  clots  have  been  observed  in  the 
nucleus  lenticularis,  internal  capsule,  and  thalamus.  In  a  case  of 
mine  there  Avere  lacunar  in  the  outer  division  of  both  lenticular 
nuclei,  and  in  the  left  external  capsule.  These  were  seen  in  the 
fresh  tissue,  and  were  visible  to  the  naked  eye.  Several  authors 
believe  chorea  itself  is  caused  by  a  bacillus,  and  they  accordingly 
treat  the  disease  antiseptically.  Huntington,  Jolly,  Eemak,  etc., 
describe  cases  of  "hereditary  chorea"  ("Centralblatt  f.  d.  Med. 
Wiss."). 

Clijiacteric  Insanity. — In  a  case  observed  by  Clouston  in  a 
male  there  were  atrophy  and  anaemia  of  brain  convolutions,  in- 
cipient arterial  atheroma,  dilatation  of  lateral  ventricle,  and  a 
patch  of  white  softening  in  centre  of  left  hemisphere. 

Coarse  Brain  Disease. — Insanity  from  softenings,  haemor- 
rhages, atrophies,  chronic  degenerations,  and  occasionally  tumours 
in  various  parts  of  the  encephalon.  Vide  supra  ("  Consistence  " 
and   "Size"). 

Charcot  ("Lecons  sur  les  Localisations  Cerebro-spinales,"  p.  93) 
says   that   one   of   the   lenticulostriate  branches  of  the  Sylvian 

13 


194  PATHOLOGY. 

artery  might  with  justice  be  called  the  cerebral  hsemorrhagic 
artery  on  account  of  its  size  and  its  predominant  role  in  intra- 
encephalic  htemorrhage.  He  also  states  {op.  cit.,  p.  76)  that 
whilst  hsemorrhage  is  common  in  the  central  ganglia  and  com- 
paratively rare  in  the  cerebral  lobes,  ischeemic  softening  is  more 
frequent  in  the  latter  situation.  The  patches  of  softening  are 
yellow  in  the  central  ganglia  and  cortex  and  white  in  the  medullary 
substance.  The  cortical  softening  may  be  spread  over  many 
convolutions  without  loss  of  substance.  Haemorrhages  according 
to  their  age  may  be  evidenced  by  the  presence  of  the  blood  itself, 
by  dark  spots  with  softening  (with  or  without  loss  of  substance) 
by  cicatrices,  by  dark  stainings,  or  by  cysts.  According  to  Bevan 
Lewis  the  brain  is  lighter  in  organic  dementia  due  to  softening 
than  in  any  other  form  of  acquired  insanity. 

Tumours. — "  The  most  common  intra-cranial  growths  are  tuber- 
cular and  syphilitic  ;  next  comes  glioma,  then  sarcoma,  and  then 
cancer.  Other  forms  are  rare "  (Gowers'  "  Diseases  of  the 
Brain,"  p.  199). 

Clouston  found  tumours  in  seA^en  of  thirty-six  cases  of  organic 
dementia.  In  most  of  these  seven  cases  there  was  manifest 
secondary  convolutional  lesion  through  pressure  or  irritation. 
He  found  twenty-eight  cases  of  brain  tumour  out  of  one  thousand 
autopsies.  Other  authors  say  the  proportion  is  about  two  in  a 
thousand.  In  twelve  out  of  thirty -six  cases  of  organic  dementia 
Clouston  found  very  marked  convolutional  atrophy  with  or  "vvithout 
softening.  He  concludes  that  gTOSs  brain  lesions  tend  to  cause 
mental  disease  in  two  waj^s  :  (1,)  by  reflex  or  other  irritation, 
or  excitement  of  morbid  convolutional  action  ;  and  (2,)  by  actual 
destruction,  primaiy  or  secondary,  of  conA'olutional  structure 
(p.  394). 

CoNFUSiONAL  INSANITY,  Chronic,  with  excitement. — The 
blood  vessels  are  tortuous,  twisted,  and  bent  on  themselves. 
They  are  irregularly  dilated  and  constricted.  Sometimes  the 
dilatations  resemble  aneurisms  (Spitzka,  p.  107). 

Consecutive  Insanity. — After  fevers,  protoplasm  of  nerve 
cells  cloudy,  their  pi'ocesses  stain  poorly,  their  nuclei  are  ill-marked 
(Spitzka). 

Delirium,  Acute. — (Acute  delirium,  delirium  grave,  acute 
delirious  mania.) 

(1,)  Macroscojncal. — Hypersemia  of  the  cerebral  membranes, 
sometimes  nothing  at  all  (Criesinger,  Briand,  Bra,  etc.)  Often  a 
peculiar  red  coloi'ation  of  the  gray  substance  cortical  and  central. 
Sometimes  a  violet  tinted  m.ottling  of  the  white  substance,  the 
gray  showing  nothing.     The  cord  and  its  membranes  are  similarly 


PATHOLOGY.  195 

altered,  though  to  a  less  degree  and  after  the  cerebral  change 
(Briand,  Bra).  Spitzka  states  that  an  intense  hypersemia  of  the 
brain  and  its  meninges  is  constantly  found  in  patients  dying 
during  the  excited  period,  but  that  in  those  who  die  in  the 
stuporous  period  this  is  "  sometimes  obliterated  by  a  collateral 
oedema."  "  In  all  the  brain  appeared  swollen."  Layers  of  fibrine 
(newly  formed)  and  white  streaks  consisting  of  leucocytes  have 
been  found  by  him  around  the  vessels  of  the  pia  and  cortex. 

(2,)  Micwscojncal.—"  The  cortical  ganglionic  elements  are  granu- 
lar or  opaque,  stain  pooily,  and  their  perigangiionic  spaces,  like  the 
adventitial  lymph  sheaths,  are  literally  crammed  with  the  formed 
elements  of  the  blood"  (Spitzka).  This  author  considers  the  disease 
to  be  "  the  result  of  a  vaso-motor  over-strain."  Bra  states  that  the 
blood  corpuscles  are  diminished  in  number,  and  that  Jehn  has 
observed  pigmentary  granulations  along  the  course  of  the  blood 
vessels,  and  an  increase  of  nuclei  in  the  neuroglia,  and  the  presence 
of  cells  attacked  by  fatty  degeneration  ;  further,  that  Briand  has 
observed  bacteria  in  the  blood  and  a  special  red  coloration  of  the 
internal  tunic  of  the  aorta  at  the  arch. 

Delusional  Insanity  (Monomania,  Paranoia). — Occasionally 
there  are  found  anomalies  of  skull  and  brain,  in  part  congenital, 
and  in  part  acquired  in  early  infancy,  asymmetry  of  hemispheres  or 
convolutions,  or  both,  vascular  abnormalities,  anomalies  of  minute 
cerebral  elements  (Spitzka,  p.  90).     Frequently  nothing  is  found. 

Dementia,  Terminal. — Cases  of  chronic  insanity  in  v.'hich  no 
anatomical  lesion  is  found  are  rare  (G-riesinger).  Opacity  and 
thickening  of  the  membranes ;  atrophy  of  the  brain,  particularly 
of  the  convolutions ;  chronic  hydrocephalus ;  subarachnoid 
effusions;  cortical  pigmentations;  extended  and  profound  cerebral 
sclerosis ;  granular  ependyma  are  the  lesions  commonly  met  with 
(Griesinger,  "Psych.  Krank.,"  pp.  442-443).  Considerable  atrophy 
of  the  brain  corresponds  as  a  rule  to  a  condition  of  profound 
mental  weakness  (oj).  cit,  p.  443).  Griesinger  says  (op.  cif.,  p.  422) 
the  morbid  change  is  most  frequently  found  in  the  anterior 
portion  and  superior  part  of  the  middle  portion  of  the 
cerebral  hemispheres.  B.  Lewis  states  that  extreme  atrophy  of 
the  frontal  lobe  is  found  associated  with  dementia  accompanied 
by  extreme  somnolence  and  incapacity  for  the  slightest  mental  effort. 
Spitzka  states  that  the  diminution  of  brain  weight  in  dementia  is 
considerable.  He  gives  the  macroscopical  characters  as  diminished 
size  of  brain,  enlargement  of  ventricles,  shrinking  of  convolutions, 
widening  and  gaping  of  sulci,  increased  firmness  on  section,  ready 
formation  of  gaps  in  white  substance  when  being  hardened,  strands 
of  fibres  of  a  grayish  or  brownish  tinge  or  dirty  white  colour. 


196  PATHOLOGY. 

Microscopical. — Spitzka  also  states  that  in  chronic  insanity  the 
nerve-cells  undergo  passive  atrophy,  and  still  more  frequently  an 
intensification  of  the  normal  process  of  involution..  The 
final  phase  of  the  latter  change,  destruction  of  the  cell,  is 
noted  in  the  larger  pyramids  in  extreme  dementia ;  the  nucleus 
and  cell  processes  disappearing  and  the  cell  being  represented 
only  by  an  irregular  mass  of  granules  and  pigment.  Pigmentation 
extends  to  the  smaller  pyramidal  cells,  and  is  not  limited  to 
the  larger  pyramidal  nerve-cells  as  in  healthy  middle  life.  The 
nerve-cells  are  diminished  in  number.  The  neuroglia  elements 
are  increased,  hence  the  greater  firmness  on  section.  Granular 
and  yelloAvish,  rarely  brownish  pig-mentary  matter  in  adventitia,. 
especially  at  bifiu-cation  of  vessels.  Proliferation  of  the  nuclei  in 
the  vascular  tissues  and  a  fine  granular  or  a  colloid-like  change  of 
the  muscular  coat  are  common.  General  vascular  sclerosis  (a 
sec[uel  of  the  nuclear  proliferation)  is  common,  and  a  whole  vessel 
may  degenerate  into  a  fibrous  filament,  perhaps  "svithout  a  lumen 
(Spitzka). 

Epilepsy. — (1,)  Macroscopical. — Tumours.  Osseous  spiculse. 
Cortical  erosions  and  softening.  In  50  per  cent,  of  the  epileptic 
insane  the  cornu  ammonis  is  found  atrophied  (Meynert). 
Clouston  says  that  any  irritation  may  cause  epilepsy  in  a  brain  of 
a  certain  quality,  but  that  irritation  of  the  cortical  motor  area  is. 
much  more  apt  to  cause  it.  He  calls  attention  to  the  fact  that  in 
nearly  all  cases  one  cerebral  hemisphere  is  considerably  heaAder 
than  the  other,  and  that  in  children  with  one  hemisj)here  better 
developed  than  the  other,  there  is,  in  the  majority  of  cases,, 
epilepsy.  In  Jacksonian  epilepsy  there  are  found  nearly  always, 
erosions,  adhesions,  softenings,  haemorrhages,  abscesses,  or  tumours, 
in  or  near  the  cortical  motor  area. 

(2,)  Microscojjical. — Atrophy  of  the  cortical  cells  of  the  cornu 
ammonis  (Meynert).  Degeneration  of  the  cells  of  the  second 
layer  (the  small  pyramids)  of  the  general  cortex  cerebri.  Abnormal 
excess  of  the  neuroglia  (Lewis). 

General  Paralysis. — (1,)  Macroscopical. — Durhaematomata 
(arachnoid  cysts)  between  dura  mater  and  arachnoid  (or  more 
correctlj^  speaking,  between  the  parietal  and  visceral  portions 
of  the  latter  membrane)  occur  more  frequently  than  in  other 
mental  diseases.  The  arachnoid  is  very  prone  to  be  rough 
and  granular  on  its  outer  surface ;  it  is  also  frequently 
thick  and  opaque.  Maudsley  ("  The  Physiology  and  Pathology 
of  Insanity,"  p.  456)  says,  "Great  oedema  of  the  membranes  is  one 
of  the  most  frequent  morbid  changes."  He  also  states  that  Sankey 
found  effusion  beneath   the  arachnoid    (sub-arachnoid   efiusion). 


PATHOLOGY.  197 

in  eleven  out  of  fifteen  cases.  Morbid  adhesions  between  the 
cortex  and  its  investing  membranes  constitute  the  most  character- 
istic naked  eye  lesion,  being  only  absent  in  a  small  percentage  of 
cases.  The  walls  of  the  ventricles  have  a  roughened  granular 
appearance  {condition  sahlee  of  the  French  authors) ;  this  is  well 
seen  on  the  floor  of  the  fourth  ventricle.  It  is  there  rarely 
absent  in  general  paralysis.  The  cortex  is  much  thinned  ;  it  is 
often  mottled  with  pink,  often  pale  gray,  or  of  a  uniform  dirty 
gray  hue  with  but  poorly  defined  lamination ;  the  ai'terioles  are 
frequently  coarse  and  engorged ;  these  changes  are  most  marked 
in  the  frontal  lobes,  less  advanced  in  the  parietal,  and  seldom 
seen  in  the  occipital.  There  may  be  redness  of  the  medullary 
substance  from  increased  vascularity.  There  is  frequently  general 
diminution  of  consistence.  The  average  brain  weight  is 
diminished  (Voisin,  Mickle,  Lewis). 

(2,)  Microscopical. — (a,)  Vascular  elements.  The  arterioles  of 
the  pia  and  cortex  are  distended  and  bulge  at  intervals  ;  engorged, 
tortuous,  thickened,  and  surrounded  by  nuclear  proliferations ; 
(&,)  Neuroglia  elements.  They  are  greatly  augmented.  The  cells 
are  increased  in  number  and  size,  and  their  radiating  processes  in 
number  and  thickness  (Obersteiner,  Luys,  Mickle,  Lewis). 
Auguste  Voisin  considers  the  neuroglia  to  be  true  nervous,  and 
not  connective,  tissue  {op.  cif.,  p.  459).  B.  Lewis  attaches  great 
importance  to  the  action  of  the  Deiters'  cells  (spider  cells,  lymph- 
connective  elements),  which,  according  to  him,  supplement  the 
action  of  the  blocked  lymphatic  channels,  and,  as  8,bove  stated, 
increase  in  size,  number,  etc.  ;  (c,)  Lymphatic  elements.  The 
channels  are  blocked  with  debris,  etc.);.  {d,)  Nervous  elements. 
There  is  degeneration  of  the  cortical  cells  (Mickle,  Voisin,  etc.) 
Tuczek  ("  Allg.  Zeit.")  considers  the  wasting  and  disappearance 
of  the  cortical  association  fibres  to  be  the  most  important  alteration. 
The  finest  fibres  of  the  frontal  cortex  are  first  affected,  then  the 
coarse  fibres  of  the  same  lobe,  then  the  fibres  of  the  remainder  of 
the  cerebral  cortex. 

Of  these  changes  the  vascular  are  the  first  to  show  themselves. 

Spinal  cord,  frequently  affected.  There  are  vascular  alterations. 
Sometimes  there  is  degeneration  of  the  posterior  columns. 

Idiocy. — (1,)  Macroscopical. — The  head  is  generally  small.  In 
some  cases  the  cranial  bones  are  very  thick,  the  diploe  being 
of  the  consistence  of  ivory.  This  osseous  condensation  is  often 
very  unequally  distributed  (Bra). 

Sometimes  the  cranial  bones  are  very  thin.  There  may  be  a 
prominence  visible  during  life  over  the  affected  side  when  the 
patient  is  suffering  from  porencephalus  (Griesinger). 


198  PATHOLOGY. 

The  cranial  capacity  is  usually  much  less  than  in  normal  indi- 
viduals. This  often  ai^ises  from  the  premature  ossification  of  the 
cranial  sutures  which  may  be  uniform,  giving  rise  to  micro- 
cephalus,  or  may  affect  certain  sutures  and  respect  others, 
and  thus  produce  the  dolichocephalic  cranium  projecting  either 
in  the  occipital  or  the  frontal  region. 

In  hydrocephalic  idiocy  the  head  on  the  contrary  will  be 
large,  although  the  brain  may  be  very  small. 

The  average  weight  of  the  hrain  of  male  adult  idiots  is  1188 
gTammes,  of  female,  1057,  the  average  physiological  weight 
(according  to  "Wagner  and  Broca)  being  respectively  1410  and 
1262  grammes  (Bra).  This  atrophy,  or  rather  arrest  of  develop- 
ment may  be  caused  either  by  premature  ossification  of  the 
cranial  bones  or  by  trophic  disturbances.  There  is  often  a  gi^eat 
difference  between  the  two  cerebral  hemispheres,  the  two  halves 
of  the  cerebellum,  and  the  olivary  bodies. 

The  cerebrum  may  be  markedly  asymmetrical  whilst  the 
cerebellum  is  symmetrical,  or  nearly  so. 

Hypertrophy  of  the  brain  occurs  occasionally  in  idiots. 
Griesinger  says  it  is  impossible  to  distinguish  it  during  life  from 
hydrocephalus.  He  quotes  Baillarger  as  mentioning  the  case  of 
a  child  of  four  years  of  age  in  whom  the  brain  weighed  1305 
grammes,  and  of  another  in  whom  the  body  weighed  46  pounds, 
and  the  brain  1160  grammes.  Bricquet,  Delasiauve  etc.,  have 
reported  analogous  cases. 

The  corjnis  callosum  may  be  atrophied  or  absent.  The  central 
ganglia  may  be  atrophied  on  one  or  both  sides,  the  pons  may  be 
atrophied  ;  even  the  total  absence  of  one  of  the  cerebral  hemi- 
spheres has  been  observed. 

There  may  be  ixirencepludus,  the  substance  of  the  convolutions 
and  centrum  ovale  being  more  or  less  destroyed,  and  the  resulting 
cavity  filled  with  serous  fluid  enclosed  in  a  cyst. 

Hydrocephalus  is  frecjuently  observed ;  the  fluid  sometimes 
lying  on  the  surface  of  the  brain,  sometimes  accumulating  in  the 
ventricles  only,  forming  two  pouches  which  push  the  cerebral  sub- 
stance forward  and  cause  the  frontal  region  to  project  during  life. 

The  convolutions  are  generally  thin,  narrow,  attenuated,  the 
fissures  appearing  consequently  "sadder  and  deeper.  The  frontal 
convolutions  are  those  most  frequently  irregular,  the  marginal 
coming  next  (Bra).  According  to  Luys  the  frontal  ascendant  is 
the  convolution  Avhich  most  frequently  evinces  traces  of  arrest  of 
development.  Of  the  fissures,  the  fissure  of  Sylvius  displays 
"widening  most  markedly.  The  occipital  lobe  is  often  shortened. 
It  frequently  presents  abnormally  small  convolutions  (microgyria) 
(Spitzka). 


PATHOLOGY.  199 

Griesinger  states  that  various  observers  (Stahl,  Eoseby,  ISri6pce) 
have  remarked  an  unusual  abundance  of  gray  substance  (in  the 
ordinary  localities)  in  the  brains  of  certain  idiots.  Occasionally 
new  formations  of  gray  substance  are  found  in  parts  where  gray 
matter  is  not  normally  found  (Virchow  in  an  epileptic  idiot, 
Griesinger  in  an  epileptic  whose  mental  state  he  did  not  know). 

(2,)  Microscopical. — Spitzka  observed  in  imbeciles  a  dispro- 
portionate thickness  of  the  outer  or  barren  layer  of  the  cortex 
cerebri.  This  was  general.  There  was  also  a  relative  sparseness 
of  the  cortical  ganglionic  elements,  "  particularly  noticeable  in  the 
granular  layers."  In  one  case  the  blood-vessels  were  sclerotic, 
and  there  was  a  general  preponderance  of  connective  tissue 
elements  over  the  nervous  structures  throughout.  He  also  found 
large  numbers  "  of  nuclear  bodies  surrounded  by  a  little  granular 
protoj)lasm,  and  contained  in  clear  roimd  spaces  of  the  neuroglia." 

In  epileptic  idiocy  the  nerve  cells  may  be  arrested  in  develop- 
ment (Be van  Lewis). 

Bra  says  the  most  characteristic  lesion  is  the  arrest  in 
development  of  the  capillary  net-work  of  the  cortex,  the  meshes 
being  imperfect,  the  vessels  incompletely  formed,  varicose,  and 
attacked  by  gTanular  fatty  degeneration.  Sometimes  instead  of 
vessels  little  lacunse  filled  with  blood  globules  are  observed.  The 
nerve  cells  are  slashed,  irregular,  infiltrated  with  calcareous  salts. 

H.  Major  ("Jour.  Ment.  Sci.,"  1883)  found,  in  the  sclerosed 
and  atrophied  cerebellum  of  an  epileptic  imbecile,  the  molecular 
and  granular  layers  diminished  in  thickness  with  increase  of  con- 
nective tissue  elements  in  former,  the  Deiters'  cells  being  numerous 
and  prominent,  disappearance  of  the  Purkinjean  corpuscles  in  the 
sclerosed  leaflets,  connective  tissue  in  place  of  the  white  nerve 
fibres  of  the  leaflets  ;  he  fou.nd  similar,  though  less  advanced, 
changes  in  the  cerebellum  of  a  paralytic  idiot, 

Katatonia. — (1,)  Macroscopical. — According  to  Meynert,  there 
is  ventricular  dropsy  ;  he  says  there  is  also,  perhaps,  premature 
ossification  of  the  sutures  (Verity,  "  Jour.  Nerv.  Ment.  Dis."). 
There  are  indications  of  basal  meningitis  (Meynert,  "Umfang,  etc., 
der  klin.  Psych.").  Julius  Mickle  found  ("Brain,"  1891,  Part  liii., 
p.  100)  in  one  case  patches  of  adhesion  and  decortication  at  the 
anterior  part  of  the  inferior  and  mesial  siu-faces  of  the  cerebral 
hemispheres,  "slight  thickening  and  opacity  of  the  pia-arachnoicl 
over  the  brain  base,"  and  "  great  thickening,  toughness  and 
opacity  over  the  supero-lateral,  fronto-parietal  region,  Avith  corre- 
sponding pial  oedema,  over-easy  removal  of  meninges  and  wasting 
of  gyri.  Evidence  of  old  hypersemia.  Meninges  firm  over  inferior 
surface  of  cerebellum,  resisting  firmly  when  being  cut.    Cerebellar 


200  PATHOLOGY. 

substance  pale,  relatively  to  cerebral,  and  slightly  firmish.  Pons, 
and  medulla  pink. 

(2,)  Microscopical. — Mickle's  case,  back  part  of  left  F'  ; 
vacuolation,  increase  of  nuclei  in  and  around  cell-walls,  slight 
tortuosity  of  some  of  the  blood-vessels. 

Meynert  says  there  are  microscopic  exudations  (Verity). 

Mania. — In  acute  mania  very  frequently  nothing  whatever  is 
found.  The  most  constant  appearance  is  hypersemia  more  or  less 
extensive  of  the  membranes  and  of  the  brain  substance,  cortical 
and  medullary,  peripheral  and  central  (Griesinger,  Bucknill  and 
Tuke,  Spitzka,  Bra).  But  this  is  seen  in  other  mental  diseases  and 
even  in  sane  persons  (Sj^itzka).  The  microscope  reveals  nothing 
characteristic.  In  the  suh-acute  forms  Luys  says  the  membranes 
are  thickened,  and  the  cortical  substance  is  thinned  and  sometimes 
indurated.  The  deep  layers  of  the  cortex  may  be  hypersemic. 
Several  of  the  above-quoted  authors  include  acute  delirium  under 
the  head  of  Mania.  In  the  chronic  forms  Luys  states  that  more 
or  less  general  atrophy  of  the  cerebral  lobes  is  found.  The  nerve- 
cells  according  to  him  are  irregularly  shaped,  yellomsh,  and 
in  some  places  have  altogether  disa|)peared  (Bra).  (See 
"  Dementia,  Terminal.") 

Melancholia. — Nothing  characteristic.  Sometimes  hyper- 
semia  of  cerebral  membranes  and  substance,  much  more  frequently 
ansemia,  occasionally  (especially  in  the  stuporous  cases)  oedema. 
But  all  these  appearances  are  found  in  sane  persons  dying  from 
fever,  phthisis,  and  other  diseases  (Spitzka). 

Meynert  ("  Bau  der  Gross-Hirnrinde,"  etc.)  mentions  the 
presence  of  free  nuclei  in  acute  melancholia  with  trophic  dis- 
turbances and  proliferation  of  the  nuclei  of  the  ganglion  cells  in 
excited  (erethische)  melancholia. 

For  the  morbid  conditions  in  chronic  cases  tending  towards 
dementia  see  "Dementia,  Terminal." 

Periodical  Insanity. — In  advanced  stages  the  arteries  are 
found  twisted,  tortuous,  reduplicated,  sacculated  (Spitzka,  p.  107). 

Puerperal  Insanity. — If  occurring  after  severe  post-partura 
haemorrhage,  marked  pallor  of  brain  substance. 

Senile  Insanity. — (1,)  Macroscopical. — Thickening  of  cranial 
bones.  Opacity  of  arachnoid  with  thickening.  Morbid  adhesions 
between  cortex  and  its  investing  membranes  in  senile  mania. 
Atheroma  and  dilatation  of  arteries.  Atrophy  of  cerebral  sub- 
stance with  softening  and  loss  of  weight. 

LacuucB  in  white  substance.  The  lesions  may  be  localised  in 
the  frontal  lobes  or  general. 


PATHOLOGY.  201 

(2,)  Microscopical. — Meynert  ("  Bau  der  Gross-Hirnrinde,"  etc.) 
describes  and  depicts  a  large  cortical  pyramidal  cell  with  a  sharply 
oval  nucleus  containing  a  tripartite  nucleolus ;  the  latter  (the 
tripartite  nucleolus)  he  considers  distinctly  pathological ;  he 
found  it  in  the  cortex  of  a  man  aged  70,  in  whose  brain  there  were 
also  nuclear  proliferations  and  masses  of  pigment  along  the  course 
of  the  vessels  with  colloidal  heaps  in  the  white  substance.  Spitzka 
states  that  a  destruction  of  the  large  pyramidal  cells  is  noted 
in  advanced  senility  as  in  extreme  dementia  ;  the  nucleus  becomes 
obscured  or  disappears,  and  the  cell  processes  separate  and  also 
disappear  ;  finally  nothing  but  an  irregular  mass  of  granules  and 
pigment  is  left  to  represent  the  cell.  He  says  micro-chemistry  has 
demonstrated  that  this  is  not  a.  fatty  degeneration.  In  senile 
dementia  the  capillaries  are  dilated.  The  vascular  sheaths  are 
loaded  with  pigment.  The  peri- vascular  spaces  are  dilated. 
Neuroglia  broken  down  in  patches  within  which  only  molecules 
and  nuclei  can  be  detected.  Grranular  degeneration  going  on  to 
molecular  disintegration  of  nerve  cells,  especially  lai^ge  pyramids. 
The  nerve  fibres  are  coarse,  twisted,  irregular,  and  sometimes 
broken  up  (Bucknill  and  Tuke). 

Syphilitic  Insanity. — There  may  be  gummata  or  gummatous 
infiltration  (disseminated  miliaiy  nodules  of  Engelstadt  and 
Lancereaux).  The  former  occur  most  frequently  in  the  dura 
mater  and  the  sub-arachnoid  space.  They  are  of  two  varieties  : 
(1,)  Somewhat  hard,  white,  dry,  circumscribed  tumours  of  varying 
size  ;  (2,)  Grayish  red,  moist,  gelatinous,  semi-transparent  masses. 
They  are  formed  from  the  round  and  stellar  cells  and  the  nuclei 
of  the  meshes  of  the  normal  intercellular  tissue,  and  at  their  peri- 
phery the  cellular  infiltration  fades  gradually  into  the  healthy 
tissue.  There  may  be  sclerosis  (sclerotic  hyperplastic  encephalitis 
of  Hay  em)  diffuse,  limited  to  one  convolution,  or  scattered  in 
isolated  patches  ;  the  blood-vessels  are  dilated  and  contain  leuco- 
cytes in  their  peri- vascular  sheaths ;  the  neuroglia  cells  are 
swollen  and  contain  several  nuclei ;  atrophy  and  fatty  degenera- 
tion of  the  nervous  elements.  The  blood-vessels  may  only 
participate  in  the  above  lesions  or  they  may  be  the  sole  structure 
affected  ;  the  lesion  is  situated  under  the  endothelium ;  it  is  a  sort 
of  membrane  formed  of  giant  cells  and  connective  elements  (Bra). 
Syphilis  (according  to  Henbner)  attacks  only  the  middle-sized 
and  smaller  arteries  of  the  brain,  whilst  atheroma  attacks  any  of 
the  arteries  of  the  body  and  only  the  greater  and  middle-sized 
arteries  of  the  brain  (Stretch  Dowse,  "  Syphilis  of  the  Brain  "). 
There  may  be  lesions  which,  according  to  Fournier  and  others, 
are  only  distinguishable  from  the  lesions  of  diffuse  interstitial 


■202  PATHOLOGY. 

meningo-enceplialitis  by  a  greater  preponderance  of  the  meningeal 
alterations  (Bra).  There  are  no  specific  lesions  in  cerebral 
syphilis.      All  is  inflammation,  proliferation,  degeneration  (Bra). 

Toxic  Insanity. — Alcoholic  Insanitij. — (1,)  Macroscopical. — 
Arachnoid  thickened  and  opaque.  Fatty  degeneration  and  vari- 
cose dilatation  of  the  vessels  of  the  pia ;  here  and  there 
extravasations  of  blood  ;  occasionally  adhesions  of  the  pia  to  the 
convolutions,  as  in  general  paralysis ;  arterial  atheroma ;  induration 
of  encephalic  tissue ;  localised  softenings ;  hsemorrhagic  foci ; 
limited  congestions. 

(2,)  Microscopical. — Xumerous  proliferating  nuclei  on  the  walls 
of  the  blood-vessels,  the  latter  being  coarse  and  tortuous.  Fatty 
degeneration  of  large  pyramidal  and  spindle  cells.  Increase  of 
connective  tissue  elements  (Griesinger,  Magnan,  Bra,  Lewis). 

The  vessels,  nerve-cells  and  connective  elements  of  the  spinal 
cord  are  also  frequently  affected. 

Saturnine  Insanity. — -The  brain  contains  lead.  It  is  ansemic, 
yellowish  resistant,  sometimes  osdematous.  The  convolutions  are 
hard  and  seem  crowded  together.  In  satui^nine  pseudo-general 
paralysis  adhesions  have  been  observed  between  the  meninges  and 
the  convolutions,  and  between  the  convolutions  themselves  (Bra). 

Trau^niatic  Insanity. — Adhesions  between  the  cortex  and  its 
investing  membranes,  the  result  of  chronic  meningo-cerebritis,  are 

very  frequent  (Bevan  Lewis). 

C— MORBID  ANATOMY  OF  SYMPTOMS. 

Disorders    and    Defects    of    Cutaneous   Sensibility. 

Nearly  all  authors  agree  in  the  view  that  lesions  of  the  posterior 
third  of  the  hinder  limb  of  the  internal  capsule  cause  ansesthesia, 
but  there  are  differences  of  opinion  as  to  the  cortical  centre 
for  touch  (that  is,  the  centre  in  which  tactile  sensations  become 
perceptions),  Ferrier  placing  it  in  the  hippocampal  region,  Luciani 
and  Sepilli,  Gowers,  and  others  locating  it  in  the  "motor"  area 
and  the  region  behind  it.  Fiechsig  has  traced  the  sensory  fibres 
to  the  parietal  and  central  region,  "roughly  speaking,  the  part 
of  the  cortex  lying  under  the  parietal  bone  "  (Gowers). 

Gowers  quotes  Demange's  case  of  extensive  cortical  lesion  con- 
fined to  the  outer  surface  of  the  right  hemisphere,  and  symptom- 
atised  by  left  hemiansesthesia,  hemianalgesia,  loss  of  temperature 
sensation,  and  other  sensory  defects.  In  support  of  this  view  (and 
cases  bearing  it  out  are  from  time  to  time  reported  in  the  journals), 
is  the  case  reported  by  Mason  ("Lancet,"  May  30th,  1891), 
in  which  there  was  abscess  of  the  lower  part  of  the  right 
central  convolutions  with  paralysis  of  and  loss  of  sensation  in  the 


PATHOLOGY.  203 

left  arm ;  sensation  and  motor  power  returned  after  trephining 
and  evacuating.  In  another  case  ("  Brit.  Med.  Jour."  Supplement, 
Aug.  1,  1891,  p.  35),  a  blow  with  a  hammer  on  the  left  side  of  the 
head  caused  fracture  over  the  fissure  of  Rolando.  There  ensued 
aphasia,  right  hemiplegia,  and  right  hemiansesthesia.  Postempski 
removed  the  depressed  bone  over  an  area  of  three  square  centi- 
metres. Three  hours  afterwards  the  hemiplegia  had  almost 
disappeared,  but  there  Avere  still  zones  of  ansesthesia  on  the 
outer  aspect  of  the  limbs.     These  zones  disappeared  in  six  days. 

Of  forty-four  cases  (organic  dementia,  senile  dementia,  idiocy, 
general  paralysis,  melancholia)  in  which  I  found  well  marked 
cerebi'al  macroscopical  lesions,  nineteen  had  suffered  from  dis- 
turbances of  cutaneous  sensibility ;  sixteen  of  these  had  suff"ered 
from  anaesthesia  and  analgesia,  unilateral  in  ten  cases ;  three 
had  been  troubled  with  cutaneous  irritation,  formication,  etc. 

In  nine  of  the  cases  of  anaesthesia  the  lesions  affected  the  cortical 
motor  area,  seven  being  destructive,  one  (general  anaesthesia)  from 
pressure  ;  and  one  (hemiansesthesia)  from  pressure  and  inflam- 
mation. Of  these  nine  cases,  four  were  unilateral  Avith  destructive 
lesions  of  the  opposite  motor  area ;  and  in  one  (the  case  of 
hemiansesthesia  from  pressure,  etc.,  above-mentioned)  there 
was  a  tumour  in  the  ojsposite  temporal  lobe  with  membranous 
adhesions  over  the  central  gyri  and  base  of  the  second  frontal 
convolution. 

There  was  softening  of  the  opposite  corpus  striatum  in  two 
cases  of  hernianeesthesia,  in  one  of  which  the  loss  of  feeling  was 
most  marked  in  the  foot;  and  in  one  case  where  the  paralysis 
of  sensation  was  at  first  unilateral  and  afterwards  bilateral,  both 
lenticular  nuclei  were  softened.  The  anaesthesia  was  most  marked 
on  the  face  and  arms. 

In  two  cases  the  median  surface  of  the  cerebrum  was  affected, 
one  unilateral  as  to  the  anaesthesia  and  opposite,  there  being  a 
destructive  lesion  confined  to  the  gyrus  fornicatus  (which  is 
interesting  in  the  light  of  Horsley  and  Schaefer's  experiments  on 
that  region),  the  other  bilateral,  and  in  it  the  cerebellum  was 
softened  on  the  same  side  as  the  cerebrum.  In  one  case  a 
clot  in  the  right  lobe  of  the  cerebellum  caused  (doubtless  by 
pressure)  left  hemianaesthesia.  In  one  case  of  general  anaesthesia 
the  right  hippocampus  and  cornu  ammonis,  the  tip  of  the  left 
temporal  lobe  and  the  posterior  parts  of  both  thalami  were  soft 
and  violet  coloured,  and  the  cerebellum  was  congested.  In  all 
the  three  cases  with  cutaneous  irritation  the  temporal  and  occipital 
lobes  Avere  diseased ;  in  one  there  was  in  addition  superficial 
discoloration  of  the  fronto-parietal  region,  and  in  another  a 
durhaematoma  over  the  convexity  of  both  hemispheres. 


204  pathol(j(tY. 


Auditory  Disturbances, 


Xearly  all  authorities  are  agreed  that  the  cortical  centre  for 
hearing  is  in  the  temporo-sphenoidal  lobe,  Gowers,  Ferrier  and 
others  locating  it  in  the  first  convolution  of  that  lobe.  Meynert, 
however,  gives  it  a  more  extensive  area  than  this  particular  con- 
volution. Luys  places  it  in  the  occipital  lobe,  and  especially 
in  the  cuneus.  Lucia ni's  experiments  on  dogs  led  him  to  the  con- 
clusion that  the  perceptive  auditory  area  includes  the  whole  of  the 
temporal  lobe,  and  radiates  from  there  to  the  parietal  and  frontal 
regions,  the  hippocampus,  and  the  cornuammonis  ("  Brain,"  July, 
1884).  Schaefer  ("Brain")  found  no  deafness  after  removal  of 
both  temporal  lobes,  but  says  the  animals  appeared  to  be  idiotic 
or  stupid.  AVestphal  and  Gray  have  had  cases  of  temporal  lesion 
without  word-deafness  or  any  deafness,  but  with  great  loss 
of  memory  ("Jour.  Nerv.  and  Ment.  Dis.").  Bevan  Le^vis  has 
found  temporal  lesions  where  there  have  been  auditory  hallucina- 
tions, especially  in  alcoholic  cases. 

Of  the  forty-four  above-mentioned  cases  of  mine  twelve  had 
ascertained  auditory  disturbances,  seven  hallucinatory.  In  six  of 
these  seven  the  temporo-sphenoidal  lobe  was  affected,  in  three 
bilaterally,  in  two  unilaterally,  and  in  all  extending  to  other 
lobes  ;  the  lesions  Avere  either  superficial  softenings  or  membranous 
adhesions,  and  in  one  case  a  tumour  in  one  temporal  lobe  -with  a 
small  focus  of  ramollissement  in  the  other.  The  seventh  patient  had 
suffered  from  hallucinations  some  time  before  admission,  but  not 
whilst  in  the  asylum  ;  the  under  surface  of  one  lateral  lobe  of  the 
cerebellum  was  grooved  and  indurated  so  that  the  auditory  dis- 
turbances may  have  been  caused  by  irritation  of  the  nerve  nuclei 
in  the  medulla.  It  is  right,  however,  to  mention  that  there  was 
an  old  durhsematoma,  and  that  the  occipital  lobes  were  slightly 
softened  The  eighth  case  was  one  of  word  deafness.  There  was 
softening  of  the  second  and  third  temporo-sphenoidal  convolutions 
on  both  sides  ;  there  Avas  also  arachnoid  effusion  over  the  left 
central  and  both  parietal  regions.  Tavo  other  cases  disj^layed 
slight  deafness  AA^th  sloAA^ness  of  mental  reaction.  In  one  the  right 
supra-marginal  gyrus  AA'as  softened ;  in  the  other  the  right  first 
temporal  Avas  so  affected,  and  the  left  operculum  AA^as  depressed  on 
the  island  of  Eeil,  by  the  abnormally  large  cjuantity  of  serous 
fluid,  causing  an  indentation.  In  the  tAvo  remaining  cases  there  Avas 
extreme  deafness.  In  one  the  membranes  were  adherent  OA^er  the 
temporo-sphenoidal  and  occipital  lobes  on  both  sides  ;  in  the  other 
there  was  softening  of  both  lenticular  nuclei,  and  in  the  right 
internal  capsule  a  hsemorrhagic  focus  encroaching  on  the  lenticular 
nucleus.     A  Avatch  could  not  be  heard  Avhen  in  contact  AAdth  the  left 


PATHOLOGY.  205 

ear,  and  only  at  a  distance  of  an  inch  and  a  half  from  the  right. 
In  one  of  the  cases  with  hallucinations,  a  general  paralytic  in 
whom  there  were  almost  universal  adhesions,  there  was  a  species 
of  deafness  which  was  rather  word  deafness  than  mere  defect  of 
hearing. 

Visual  Disturbances. 

The  visual  sphere  at  first  limited  to  the  angular  gyrus  {pli 
coarbe)  by  Ferrier,  and  to  the  occipital  lobe  by  Munk,  has  been 
extended  by  Tamburini  and  Ferrier  to  both  these  regions,  and  by 
Luciani  (in  dogs)  to  the  occipito-temporal  region  and  parietal  region 
of  the  vertex  ("Brain");  and  indeed,  Goltz  says  removal  of  any 
portion  of  the  hemispheres  causes  dimness  of  vision,  but  that  this 
is  greater  when  the  occipital  lobes  are  removed  than  when  the 
frontal  are  so  treated.  According  to  Luciani,  bilateral  homony- 
mous hemiopia  is  the  most  frequent  symptom  of  occipital  lesion. 
Bechterew  says  the  visual  area  includes  the  whole  of  the  occipital 
and  part  of  the  parietal  lobes,  and  extends  from  the  temporal  to 
the  median  surface.  He  says  there  are  two  regions,  one  presiding 
over  the  retina  of  the  same  side,  the  other  over  that  of  the  opposite 
side.  Luciani  and  Goltz  state  that  the  blindness  soon  passes  off, 
leaving  mental  or  psychical  blindness  (Seelenblindheit).  According 
to  Munk  each  occipital  lobe  receives  fibres  from  both  eyes — from  its 
own  side  of  each  eye,  and  removal  of  one  lobe  causes  hemiopia, 
removal  of  both  total  blindness.  This  is  of  course  denied  by  the 
above  experimenters.  Luciani  and  Sepilli  limit  the  visual  zone  in 
monkeys  to  the  occipito-parietal  region  ("Allg.  Zeit.,"  1887). 
Hysterical  patients  with  hemianaesthesia  are  amblyopic,  not  hemi- 
opic  on  the  anaesthetic  side.  GoAvers  says  he  has  seen  a  few  instances 
of  this  "crossed  amblyopia"  in  Avhich  there  was  certainly  organic 
disease.     He  also  states  that  several  others  have  been  recorded. 

In  Demange's  case  there  was  amblyopia  mth  loss  of  colour 
vision  in  the  left  eye  (ride  snpxi).  Seguin  ("Jour.  Nerv.  Ment. 
Dis.")  collected  a  series  of  forty-five  cases  of  hemiopia  in  which 
there  were  lesions  of  the  occipito-angular  region,  the  tracts 
leading  to  it,  or  of  the  posterior  part  of  the  thalamus. 

In  a  paper  read  at  the  Liverpool  Medical  Institution,  Glynn 
described  a  case  of  word  blindness  with  restriction  of  visual 
fields,  caused  by  depressed  fracture  of  the  superior  postero-parietal 
region  of  the  skull  an  inch  from  the  lambdoiclal  suture,  and 
mostly  on  the  right  side. 

Nine  of  my  cases  suffered  from  visual  troubles.  In  two, 
vision  was  slightly  defective;  in  one  of  these  there  was 
softening  of  the  second  and  third  temporal  convolutions  on  both 
sides,  with  an  arachnoid  efiusion  extending  over  the  convexity 


206  PATHOLOGY. 

from  the  tip  of  the  occipital  lobes  to  the  central  gyri.  In  this 
case  the  defect  was  partly  psychical ;  in  the  other  the  arachnoid 
was  adherent  over  the  occipital  lobe,  and  there  were  superficial  dis- 
coloration of  parts  of  the  frontal  and  parietal,  and  softening  of 
part  of  the  temporal  convolutions  on  the  right  side,  "with  a  focus  of 
softening  imj)licating  the  cuneus,  precuneus,  superior  parietal 
lobule,  and  gyrus  angularis  on  the  left.  In  another  case  Avith 
extensive  cortical  lesions  the  patient  was  nearly  blind,  but  he  had 
cataract  of  both  eyes.  Another  patient  could  only  distinguish 
light  from  darkness  ;  in  his  case  there  was  parieto-temporal 
softening  on  the  right  side.  On  the  left  there  was  atrophy  of  the 
lenticular  nucleus,  and  the  first  temporal  convolution  was  softened ; 
the  right  lobe  of  the  cerebellum  was  also  soft  and  atrophied.  In 
another  case  there  was  loss  of  vision  of  the  left  eye,  and  later  on 
visual  hallucinations  appeared  ;  the  opposite  gyrus  fornicatus  was 
softened,  and  there  were  small  sclerotic  portions  scattered  through 
the  cortex  of  both  hemispheres.  Another  patient  had  in  addition 
to  left  hemiplegia,  defective  vision  of  the  left  eye.  There  were  foci 
of  softening  in  the  right  frontal  and  temporo-parietal  regions,  and 
the  membranes  were  adherent  over  the  right  occipital  lobe  ;  the 
left  hemisphere  was  macroscopically  normal.  A  seventh  case 
sufi"ered  from  great  restriction  of  the  left  visual  field  or  from  hemi- 
opia  of  the  left  qjq,  affecting  the  right  side  of  the  retina  ;  there  were 
adhesions  over  both  occipital  lobes,  and  a  destructive  lesion  of  the 
left  frontal  lobe.  In  the  two  remaining  cases  there  was  no  ascer- 
tained diminution  of  visual  power,  but  in  one  there  were  visual 
hallucinations,  and  the  left  corpus  striatum  was  softened.  In  the 
other  there  were  delusions  of  identity  based  doubtless  to  a  great 
extent  on  visual  illusions ;  the  cerebellum  Avas  congested  with  dis- 
eased A^essels  and  probably  softening,  leading  finally  to  haemorrhage 
into  its  substance.  There  were  lacunae  in  both  lenticular  nuclei, 
and  the  columns  of  Burdach  were  slightly  sclerosed  on  both  sides. 

Olfactory  and  Gustatory  Disturbances. 
Ferrier  localises  the  centre  for  smell  in  the  subiculum  cornu 
ammonis,  and  that  for  taste  in  the  lower  part  of  the  middle 
temporo-sphenoidal  convolution.  That  there  is  a  subordinate 
centre  for  the  sense  of  smell  in  the  subiculum  is  probable,  as  some 
of  the  fibres  of  the  olfactory  nerve  pass  directly  to  this  convolution, 
and  disease  adjacent  to  these  fibres  has  caused  loss  of  smell  on 
the  same  side  (Gowers).  That  there  is  a  centre  in  the  opposite 
hemisphere  is  proved  by  the  fact  that  disease  of  the  posterior  part 
of  the  internal  capsule  ("sensory  crossway  ")  gives  rise  to  anosmia  of 
the  opposite  side.  That  this  olfactory  area  is,  partly  at  least,  on  the 
outer  surface  of  the  hemisphere  is  shown  by  Demange's  case  already 


PATHOLOGY.  207 

mentioned,  in  which  there  was,  in  addition  to  the  other  symptoms, 
loss  of  smell  and  taste  on  the  side  opposite  to  the  lesion  (Gowers). 
According  to  Luciani,  it  extends  outwards  and  upwards  from  the 
cornu  ammonis  and  hippocampal  region  to  the  parietal  and 
frontal.  He  thinks  the  gustatory  centre  is  close  to  the  olfactory. 
More  recently  (1886)  Luciani  and  Sepilli  found  that  in  animals, 
injury  of  the  region  in  front  of  and  near  the  Sylvian  fossa,  or 
(especially)  of  the  cornu  ammonis,  caused  decided  bluntness  of  the 
sense  of  smell.  BIoavs  on  the  head,  especially  on  the  vertex  or 
occiput,  sometimes  cause  loss  of  smell  and  taste  Avhich  may  be 
permanent.  That  this  is  caused  by  contrecoup  is  not  borne  out  by 
analogy,  as  blows  over  the  lower  part  of  the  left  motor  area  cause 
symptoms  distinctly  referable  to  the  hemisphere  injured  and  not 
to  any  other  part  of  the  encephalon.  Broca  believed  the  gyrus 
fornicatus  to  be  functionally  related  to  the  sense  of  smell. 
Meynert  is  also  of  that  opinion. 

In  only  two  of  my  cases  were  there  decided  and  well  ascer- 
tained olfactory  troubles,  and  one  of  these  was  a  case  of 
hypochondriacal  general  paralysis  with  cortical  adhesions  every- 
where, and  an  arachnoid  effusion  over  the  base  of  the  first  frontal 
encroaching  on  the  ascending  frontal  convolution.  There  Avas  also 
aneurism  of  the  descending  aorta.  The  patient  from  an  early 
stage  of  his  general  paralysis  suffered  from  an  almost  complete 
abolition  of  the  sense  of  smell.  He  could  distinguish  strong  snuff 
and  pepper  by  sight,  but  not  by  smell ;  later  he  had  disagree- 
able olfactory  hallucinations  and  said  he  smelt  offensively, 
and  that  he  annoyed  those  about  him.  The  other  patient  was 
completel}^  anosmic.  There  was  a  large  deep  focus  of  softening 
affecting  parts  of  the  first,  second,  and  third  frontal,  and,  to  a 
slight  extent,  the  island  of  Keil.  The  arachnoid  was  slightly 
adherent  over  both  occipital  lobes.  The  anterior  cerebral  artery 
was  exceedingly  small,  much  smaller  than  the  right,  probably 
owing  to  embolism.  The  most  feasible  explanation  of  the  anosmia 
is  either  that  the  frontal  cortex  has  olfactory  functions  in  man, 
or  that  the  ischsemia,  Avhich  caused  the  cortical  necrosis,  starved 
the  head  of  the  caudate  nucleus,  thus  acting  on  the  opposite 
nostril;  and  also  deprived  the  olfactory  bulb  of  blood,  so  acting  on 
the  nostril  on  the  side  of  the  lesion.  Yet  this  hardly  bears  out 
Luciani's  view  that  (contrary  to  the  arrangement  of  the  other  sen- 
sory nerve  tracts)  the  direct  fasciculus  is  larger  than  the  crossed 
one.    The  occipital  lesions  may  have  had  some  effect  in  both  cases. 

Meynert  states  that  the  head  of  the  nucleus  candatus  is  very 
large  in  animals  Avith  the  sense  of  smell  very  keen ;  he  also 
says  the  yelloAV  nucleus  of  Luys  is  in  close  structural  relationship 
with  the  olfactory  lobe  (Ranney,  "Jour.  Nerv.  and  Ment.  Dis."); 


208  PATHOLOGY. 

and  the  recent  researches  of  Steiner  on  bony  fishes  tend  to  prove  by 
analogy  that  the  human  corpus  striatum  is  a  way  station  for 
olfactor}^  impressions  in  their  course  from  the  sensory  organ  to 
the  brain  mantle.  He  states  that  the  great  brain  of  the  shark  is 
merely  an  olfactory  centre,  and  that  the  vertebrate  cerebrum  has 
developed  phylogeneticallv  out  of  the  olfactory  organs  ("Brain," 
1890,  p.  396). 

The  foregoing  sensory  areas  (auditory,  visual,  cutaneous,  and 
olfactory),  overlap  each  other  in  the  postero-parietal  and  hippo- 
campal  regions  in  animals.  In  man  Luciani  and  Sepilli  do  not 
think  there  is  any  region  common  to  them  all  ("Allg.  Zeit.,"  1887). 

Motor  Symptoms, 
The  part  of  the  cerebral  cortex  concerned  in  voluntary  motion 
in  man  is,  roughly  speaking,  the  superior  middle  region,  or  more 
accuratel}^,  the  two  ascending  convolutions  (frontal  and  parietal), 
the  paracentral  lobule,  the  superior  parietal  lobule,  part  of  the 
precuneus,  and  the  posterior  part  of  the  third  or  inferior  frontal 
convolution.  Most  clinicians  and  pathologists  seem  to  agree  on 
this  point,  although  this  area  is  not  quite  co-extensive  with 
that  mapped  out  by  the  experimental  physiologists.  SchifF 
and  Brown-Sequard  deny  the  existence  of  a  special  cortical 
motor  area.  Goltz,  formerly  the  strongest  advocate  of  this 
negative  "vdeAV,  now  admits  that  ablation  of  the  "motor  zone" 
causes  permanent  motor  defect.  Charcot  and  Pitres  limit  the 
motor  area  to  the  central  convolutions  and  the  paracentral  lobule. 
The  cerebral  cortex  does  not  control  individual  muscles  but 
muscular  movements.  Horsley  and  Schaefer  localise  in  the 
gyrus  marginatus  the  centre  for  the  trunk  muscles.  The  other 
"motor  centres"  are  placed  in  the  motor  area  in  the  following 
order  from  above  downwards — leg,  arm,  face,  lips,  tongue. 
This  order  is  not  alwaj^s  borne  out  by  clinico-pathological 
experience.  GoAvers  thinks  there  is  probably  no  sharp  limitation 
between  the  "  centres,"  at  an}'-  rate  between  the  centres  for  the 
extremities.  Luciani  found  (and  all  his  experiments  are  borne 
out  by  Sepilli's  clinico-pathological  observations)  that  removal 
of  one  centre  affects  others,  but  to  a  less  degree.  Von  Gudden's 
experience  was  somewhat  similar  to  that  of  the  three  last-named 
observers.  In  disease  of  the  motor  cortex  and  (according  to  Luciani) 
of  the  parietal  region  behind  it,  the  patient  loses  the  ability  to 
localise  the  limbs  in  space.  If  his  eyes  are  closed  and 
one  of  his  paralysed  limbs  held  in  any  posture  by  the 
observer,  he  (the  patient)  cannot  describe  where  the  limb  is, 
or  imitate  the  posture  with  the  sound  limb.  Bell  called  this  phe- 
nomenon loss  of  the  "  musciilar  sense  ; "  others  believed  that  the 


PATHOLOGY.  209 

ability  of  localising  a  portion  of  the  body  in  space  depended 
on  the  cutaneous  sensibility,  but  the  phenomenon  above  described 
is  observed  when  the  cutaneous  sensibility  is  intact.  Meynert 
believes  the  muscular  sense  is  a  function  of  the  cerebellum,  this 
organ  receiving  the  impressions  from  the  cerebral  cortex. 
Cramer  and  others  descrilje  hallucinations  of  the  muscular  sense 
(in  paranoia,  etc.).  Gowers  found  loss  of  the  muscular  sense 
where  there  was  disease  of  the  corpus  striatum  and  internal 
capsule  without  cortical  lesion,  so  that  the  symptom  is  not 
diagnostic  of  disease  of  the  cortex. 

Sharkey  reported  a. series  of  six  cases  ("Lancet,"  1883)  strongly 
supporting  the  generally  accepted  localisation  of  the  motor  area. 
In  his  summary  he  states  that  he  has  never  seen  destructive  lesion 
of  that  region  unaccomj)anied  by  motor  paralysis.  This  has  also 
been  my  experience,  though  I  cannot  agree  with  the  statement 
that  destructive  lesions  confined  to  the  regions  outside  the  motor 
area  are  never  accompanied  by  paralysis.  This  is  certainly  not 
the  case  so  far  as  the  right  hemisphere  is  concerned.  Cases 
supporting  the  view  that  the  convolutions  above  named  con- 
stitute the  area  or  the  greater  part  of  the  area  for  voluntary 
motion  are  constantly  being  reported,  so  that  it  will  be  un- 
necessary to  go  into  the  details  of  such  cases. 

In  thirty-nine  of  my  cases  there  was  paralysis  or  paresis  of 
voluntary  motion,  and  in  thirty -six  of  them  on  the  side  opposite 
the  lesion.  The  other  three  were  cases  of  right  hemiparesis, 
and  in  each  case  the  right  half  of  the  cerebellum  Avas  dis- 
eased. Nine  of  the  thirty-six  cases  presented  no  lesions  in 
the  motor  area,  and  in  seven  of  these  nine  there  was  left- 
sided  paralysis,  one  (bi'achio-crural  monoj^legia)  arising  from  a 
glioma  in  the  right  temporal,  another  from  an  abscess  of  the  same 
region  (in  both  of  these  there  was  Jacksonian  epilepsy),  and 
a  third  from  clot  and  softening  in  the  base  of  the  right  second 
frontal.  In  another  of  these  seven  cases  there  was  softening  of 
part  of  the  right  supra-marginal  gyrus  with  Israchio-crural  mono- 
plegia of  twenty  years'  duration,  the  arm  being  contracted  and 
atrophied;  in  another  of  the  right  gyrus  fornicatus;  and  in 
another  of  the  right  hippocampal  region.  The  seventh  was  a  case 
of  general  paralysis  with  cortical  adhesions  over  the  right  temporal 
and  orbital  convolutions  ;  there  was  facial  monoplegia  with  epilepti- 
form convulsions  succeeding  an  apoplectiform  attack.  The  prepon- 
derance of  lesions  outside  the  motor  area  in  the  right  hemisphere 
as  compared  with  the  left  (the  effects  of  the  two  which  were  outside 
in  the  latter  could  be  accounted  for  by  pressure)  shows  that  the 
former  is  less  highly  organised  than  the  latter.  Similar  cases  are 
occasionally  seen  in  the  journals,  and  in  at  least  one  case  an 

U 


210  PATHOLOGY. 

operator,  thougli  using  every  care,  failed  to  trephine  over 
the  seat  of  the  lesion,  which,  being  a  right-sided  one,  gave  rise  to 
misleading  left-sided  symptoms.  The  two  left-sided  lesions  outside 
the  motor  area,  Avlth  dextral  symptoms,  were  haemorrhagic,  and 
both  in  the  prefrontal  region.  In  one,  besides  the  clot  close  to 
the  white  substance  of  the  frontal  ascendant  gyrus,  there  were 
extensive  lesions  on  both  sides,  but  all  outside  the  motor  area. 
There  was  aphasia  with  dextral  Jacksonian  epilepsy.  The  other 
case  was  more  interesting ;  there  was  only  one  lesion,  a  dark 
brown  softening,  2  inches  l3y  1^  inches,  situated  in  the  anterior 
part  of  the  upper  and  middle  frontal  convolutions.  Six  months 
before  admission  the  patient  had  had  an  apoplectic  attack  followed 
by  right  hemiplegia,  which  passed  off  gradually  and  disappeared 
in  four  or  five  months.  Afterwards  her  gait  was  staggering  at 
times.  Seven  months  after  the  first  attack  she  had  a  slight 
apoplectiform  seiziu-e  followed  by  right  facial  monoplegia  and 
aphasia;  the  latter  amounted  at  first  to  total  loss  of  speech,  but  in 
a  f  CAv  days  there  was  only  some  indistinctness  of  articulation  (see 
"  General  Mental  Weakness,"  postea). 

Of  the  twenty-seven  cases  in  which  lesions  were  situated  in  the 
cortical  motor  area  or  the  central  ganglia,  five  of  the  cortical 
cases  did  not  conform  to  the  generally  accepted  limb-centre 
arrangement.  Xone  of  these  anomalies  could  be  accounted  for  by 
pressure.  In  a  sixth  case  in  Avhich  there  was  a  tumour  as  large  as 
a  walnut  over  the  right  ascending  convolutions  close  to  the  falx, 
all  the  limbs  were  paraljT-sed,  and  the  left  were  slightly  atrophied. 
In  two  of  the  five  cases  there  was  complete  hemiplegia  with  the 
lower  halves  of  the  central  gyri  apparently  free  from  disease;  in 
another  case  there  Avas  complete  hemiplegia  A^dth  no  lesion  above 
the  lower  third  of  the  ascending  frontal ;  in  a  fourth  there 
Avas  brachio-crural  monoplegia  AA^th  brachial  contracture,  the 
precuneus  being  very  small,  the  temporo-sphenoidal  lobe  small 
and  sclerotic,  and  the  central  gyri  apparently  normal ;  in  the 
fifth  case  there  AA^as  right  lingual  monoplegia  AAdth  lesion  of  the 
left  superior  parietal  lobule  and  precuneus,  and  left  facial  mono- 
plegia AAdth  softening  of  the  first  and  second  right  temporal 
conA'olutions  (not  included  in  the  seven  right  irregular  cases,  t)ide 
supra).  Many  such  cases  have  been  reported,  notably  one  by 
J.  Mickle,  in  which  there  was  brachial  paralysis  (right)  Avith 
atrophy  of  the  leg  centre.  In  two  cases,  Avhen  a  part  of  the  leg 
centre  Avas  remoA'ed  lay  a  distinguished  operator  to  ciu-e  convul- 
sions, the  arm  became  pai-alysed  immediately  after  the  operation. 

In  A^ery  fcAv  of  the  tAA^enty-seven  Avere  the  lesions  con- 
fined exclusiA^ely  to  the  motor  regions.  In  one  there  AA^as 
extensive  superficial  softening  with  memlaranous  adhesions  over 


PATHOLOGY.  211 

both  prefrontal  lobes.  The  right  first  temporal  convolution  was 
affected  near  its  tip.  There  Avas  a  large  quantity  of  serous 
fluid,  and  the  operculum  was  depressed  on  the  island  of  Keil, 
causing  an  indentation.  There  had  been  two  apoplectic  attacks 
followed  by  general  muscular  weakness,  aphasia  of  the  aphemic 
variety,  and  right  unilateral  con^oilsions.  Between  the  fits,  the 
patient  complained  of  headache  and  giddiness,  and  after  the  second 
the  power  of  co-ordination  was  diminished  in  both  hands.  There 
was  also  deafness  which  was  at  least  partially  word  deafness. 
Another  patient,  mentioned  under  the  head  of  "  Olfactory 
Disturbances,"  had  deep  softening  of  part  of  the  outer  surface  of 
the  jjrefrontal  lobe  supplied  by  one  of  the  branches  of  the  anterior 
cerebral.  This  focus  extended  across  the  base  of  the  third  frontal 
to  the  surface  of  the  insula.  This  patient  suffered  from  a  species 
of  slight  aphemia  (indistinct  jerking  utterance)  without  any  other 
localised  paralysis,  but  he  used  to  sit  with  his  neck  bent  forward. 

Of  the  five  cases  free  from  voluntary  paralysis  one  had  an 
extensive  lesion  in  the  prefrontal  and  insular  region  similar  to  that 
in  the  case  last  mentioned,  but  on  the  right  side.  He  also  kept 
his  head  or  rather  his  neck  always  bent  forward.  In  another  case 
there  was  dilatation  of  the  right  pupil  Avith  a  clot  ^  hy  ^  inch 
in  the  left  external  cajjsule  and  opacity  and  adhesions  of  the 
arachnoid  on  both  sides  over  the  temporal  and  occipital  lobes. 
In  this  case  the  patient  (aged  62)  Avas  seized  Avith  the  symptoms 
of  cerebral  haemorrhage  during  a  severe  attack  of  diarrhoea,  and 
never  rallied.  There  Avas  no  hemiplegia  as  far  as  could  be 
ascertained;  had  the  coma  j)assed  off  he  Avould  probably  have 
been  aphasic.  In  another  case,  chronic  epileptic  insanity,  there 
Avas  deviation  of  the  head  to  the  right  during  the  fits.  The 
cornu  ammonis  Avas  sclerosed  on  both  sides,  more  markedly  on 
the  right.  In  another  case,  suicidal  melancholia,  the  arachnoid 
Avas  slightly  adherent  over  both  occipital  lobes ;  there  Avere  many 
dark  points  in  the  Avhite  substance  ;  the  aortic  semilunar  valves 
Avere  thickened.  The  remaining  case  has  been  already  described 
(eighth  case  under  head  of  "  Auditory  Disturbances"). 

There  Avas  pupillary  inequality  in  sixteen  cases ;  the  dilated  pupil 
AA^as  on  the  side  opposite  in  tAvelve  cases  of  destructive  lesion,  and  in 
one  case  of  tumour.  In  one  case  of  clot  the  dilated  pupil  AA^as  on  the 
same  side.  Taa^o  cases  Avere  doubtful,  there  being  in  one  a  clot  on 
the  side  of  the  large  pupil  and  softening  of  the  inferior  parietal 
lobule  on  the  opposite  side,  and  in  the  other  case  softening  of  the 
median  surface  on  the  same  side,  and  disseminated  sclerosis  in 
both  hemispheres.  In  seven  cases  the  so-called  deep  reflexes 
(knee-jerk  and  ankle  clonus)  were  much  more  marked  on  the 
side  opposite  the  lesion  than  on  the  same  side.     In  three,  tumour, 


212  PATHOLOGY. 

disseminated  sclerosis,  and  hippocampal  softening,  they  were 
absent  altogether,  and  in  one  case  the  knee-jerk  was  absent 
on  the  right  side,  but  well  marked  on  the  other;  the  form  of 
paralysis  Iseing  right  linguo-facial  monoplegia  with  defective 
speech ;  there  was  also  twitching.  Some  paraparesis,  more  marked 
on  left  side,  existed.  There  Avas  in  the  right  hemisphere  softening 
of  the  supra-mai-ginal  gyrus  and  adjoining  part  of  the  first 
temporal ;  on  the  left  side  there  were  softening  of  the  first  temporal 
and  atrophy  of  the  lenticular  nucleus,  accompanying  which  there 
was  atrophy  with  softening  of  the  right  half  of  the  cerebellum. 
This  last  lesion  most  probably  caused  the  absence  of  the  knee-jerk. 
In  three  cases  there  was  ptosis,  in  two  of  them  the  supra-marginal 
gyrus  Avas  implicated,  and  in  the  third  the  nucleus  lenticularis. 
The  corpus  striatum  (caudate  or  lenticular  nucleus,  sometimes  the 
whole  organ)  was  affected  in  six  cases,  and  apparently  this  lesion 
caused  the  paralysis.  Meynert  says  destructive  lesions  of  the 
lenticular  nucleus  cause  paralysis  of  the  opposite  side,  especially 
marked  in  the  face,  tongue,  and  arm.  Ziehen  states  that  stimulation 
of  the  anterior  part  of  the  corpus  striatum  has  the  same  effect  as 
stimulation  of  the  anterior  part  of  the  cortical  motor  area  ("Brain.") 
In  at  least  tAvo  cases  I  have  found,  Avith  lesion  of  the  lenticular 
nucleus,  the  paralysis  most  marked  in  some  or  all  of  the  parts 
indicated  by  Meynert;  one  of  these  Avas  mentioned  above  when 
speaking  of  the  deep  reflexes.  In  the  other  there  Avas  at  first 
unilateral,  after Avards  bilateral,  paralysis  of  the  face,  tongue,  and 
arm,  Avith  lingxial,  labial,  and  facial  tremor.  There  AA'as  anaesthesia 
of  the  paralysed  parts.  There  Avas  brachial  contracture,  but  only 
slight  crural  Aveakness.  Both  lenticular  nuclei  Avere  softened 
anteriorly.  I  Avas  present  at  an  autopsy  performed  by  Luys  on  a 
case  of  aphasia  at  the  Salpetriere  in  1878.  The  only  lesion  Avas  a 
focus  of  softening  in  the  lenticular  nucleus.  It  was  the  third  case 
of  the  kind  Luys  had  observed.  Meynert  in  support  of  his  view 
quotes  Nothnagel's  experiments  in  AAdaich  he  destroyed  the  nuclei 
lenticulares  by  injecting  a  solution  of  chromic  acid,  and  so  caused 
loss  of  spontaneous  movement.  GoAvers,  on  the  contrary,  says 
destruction  of  the  nucleus  lenticularis  does  not  cause  paralysis, 
unless  the  anterior  part  of  the  hinder  limb  of  the  internal  capsule 
is  implicated. 

Wernicke  states  that  the  caudate  and  lenticular  nuclei  are  not 
connected  Avith  the  cortex,  and  only  indirectly,  through  the  sub- 
stantia nigra,  AAdth  the  pes  pedunculi,  and  are  therefore  not  way- 
stations  for  voluntary  impulses  as  Meynert  thinks,  but  more  recent 
observers  (Luciani,  etc. )  hold  Meynert's  vieAv.  Those  AA^ho  have  seen 
Meynert's  preparations  (cleavages  and  sections)  will  not  be  sur- 
prised at  this  reversion.     Wernicke  agrees  Avith  Meynert  that  the 


PATHOLOGY.  213 

tegmentum  (directly  connected  with  these  nuclei)  is  the  reflex 
path. 

In  several  cases  with  cervical  muscular  weakness  the  insula  was 
found  diseased.  There  were  fourteen  cases  of  aphasia  of  various 
degrees,  slight  aphemia  or  dysphasia,  amnesic  aphasia,  complete  loss 
of  speech,  total  inability  to  speak  from  early  infancy,  there  being  no 
congenital  deafness.  In  these  the  posterior  part  of  Broca's  (the 
third  or  inferior  left  frontal)  convolution,  or  (in  one  idiot)  the  left 
temporal  lobe  was  either  intrinsically  diseased  or  subjected  to 
pressure.  In  some  cases  the  insula  was  also  aff'ected.  In 
two  cases  of  general  pai-alysis  the  symptoms  were  aj)parently 
anomalous,  there  being  left  brachial  or  brachio-facial  monoplegia, 
but  the  central  gyri  were  found  to  be  specially  diseased  on  the 
right  side,  and  the  third  frontal  on  the  left.  The  right  third 
frontal  Avas  affected  in  several  cases,  but  in  none  of  these  was 
there  aphasia.  In  one  case  there  was  a  cyst  over  the  lower  part 
of  the  insula  effacing  the  convolutions ;  there  was  marked  weak- 
ness of  the  cervical  muscles,  hut  no  aphasia. 

There  were  nine  cases  in  which  Jacksonian  epilepsy  was  present; 
the  lesions  were  haemorrhages,  adhesions,  softenings,  abscess, 
tumour,  cyst  close  to  or  in  the  motor  area.  In  all  except  one  the 
convulsions  were  on  the  side  opposite  to  the  lesion.  The 
excepted  case  was  doubtful  as  there  was  softening  of  the  right 
gyrus  f  ornicatus  with  disseminated  sclerosis  in  both  hemispheres ; 
there  were  hemiplegia  and  hemianaesthesia  of  the  left  side  Avith, 
at  first,  twitching  and  tremor ;  later  there  were  convulsions 
confined  to  the  right  side.  There  Avas  one  case  of  dura  matral 
tumour  over  the  upper  part  of  the  right  central  gyri  Avithout 
any  convulsions  Avhatever.  In  nine  cases  displaying  mental  and 
motor  excitement  and  restlessness,  there  Avere  lesions  of  the 
fronto-parietal  region  or  corpus  striatum. 

General  Mental  Weakness, 

Defective  attention,  memory,  judgment  (general,  not  partial,  as  when 
there  are  delusions)  and  volition. — Griesinger  pointed  out  long 
ago  that  the  brain  degeneration  accompanying  the  mental  Aveak 
ness  of  the  chronic  forms  of  insanity  affected  especially  the 
fronto-parietal  conA'exity.  Bevan  LeAvis  says  atrophy  of  the 
brain  occurred  in  a  little  over  two-thirds  of  a  large  number 
of  cases,  and  that  the  segment  of  the  brain  most  frequently 
atrophied  Avas  the  fronto-parietal,  particularly  the  frontal  part  of  it. 
Ferrier,  Ross,  and  many  others  think  the  prefrontal  lobes  are  the 
seat  of  some  of  the  higher  cerebral  functions,  inhibition,  attention, 
observation,  etc.      Hughlings-Jackson  is  inclined  to  think  they 


214  PATHOLOGY. 

are  the  principal  seat  of  the  re-representative  cognitions  (abstract 
ideas)  and  feelings  (emotions).  Sir  J.  Crichton-Browne  considers 
it  probable  that,  in  addition  to  other  faculties  and  accjuisitions, 
the  moral  sense  and  religious  emotions  are  localised  in  them. 
Harlow's  crow-bar  case  is  an  instance  of  moral  deterioration 
caused  by  prefrontal  injurj^ 

In  three  of  four  cases  in  which  I  found  serious  destructive  lesions 
confined,  or  almost  so,  to  the  prefrontal  region,  one  right,  one  left, 
and  one  bilateral,  the  phrase,  "  Takes  notice  of  nothing,"  occurred 
in  all  the  medical  certificates.  There  was  the  usual  general  mental 
weakness  displayed  by  organic  dements,  but  a  total  absence  of 
morbid  "sensiblerie"  The  patient  with  the  left  lesion,  though  gener- 
ally apathetic,  had  explosive  outbursts  of  anger  at  times,  and  the 
bilateral  case  had  two  apoplectic  attacks  followed  by  imilateral 
epilepsy  affecting  the  whole  of  the  right  side,  and  aphasia.  Some  of 
these  symptoms  were  hoAvever,  doubtless,  caused  to  a  great  extent 
by  the  pressiu^e  of  the  abnormally  large  quantity  of  serous  fluid 
on  the  operculimi,  the  insula  being  indented  by  this  structure. 
To  make  a  digression:  an  abnormally  large  quantity  of  serous  fluid 
surrounding  a  diseased  cerebral  structure  seems  to  endanger  life 
in  tAvo  ways  :  (1,)  by  jDressure  through  its  sudden  increase  on 
account  of  diminished  excretion  or  other  cause  ;  (2,)  by  causing 
atheromatous  arteries  to  rupture  in  consequence  of  lessened 
vascular  support,  when  the  serous  fluid  is  suddenly  diminished  in 
quantity  oA^nng  to  increased  excretion  or  other  causes.  In  the. 
foiuth  case  there  were  no  naked-eye  lesions  outside  the  left 
prefrontal  lobe,  and  in  it  there  was  a  large  focus  of  brown 
haemorrhagic  softening  anteriorly.  This  patient  was  also  very 
weak  mentally,  and  also  free  from  morbid  " sensillerie ;  "  but  she 
was  sleepless,  restless,  noisy,  violent,  and  destructive.  The  latter 
sym2:)toms  resemble  those  of  acute  mania.  In  the  beginning 
and  at  the  end  of  her  illness  she  suff'ered  from  right  hemiplegia 
and  ajDhasia,  both  the  highest  and  middle  centres  of  evolution  of 
Hughlings- Jackson  being  then  affected,  whilst  in  the.  interim 
only  the  former  suffered.  In  view  of  the  connection  between 
the  prefrontal  lobe  and  the  cerebellum,  it  is  noteAvorthy  that 
two  of  these  patients  suffered  from  vertigo  and  staggering  gait  at 
times,  and  one  from  diminished  power  of  co-ordination  in 
the  hands.  The  memoiy  was  most  defective  in  patients  with 
extensive  temporal  lesions. 

Morbid    "  Sensiblerie." 
Motiveless  weeping  Avas  a  marked  symjotom  in    nine    cases, 
and  in  these  the  lesions  Avere  mostly  confined  to  the  occipito- 
temporal region  or  the  central  ganglia. 


PATHOLOGY.  215 


Delusions. 


There  were  depressive  delusions  in  nine  cases,  and  in  six  of 
these  there  were  lesions  (mostly  membranous  adhesions)  of  the 
occipital  lobes ;  in  one,  lesions  of  the  lenticular  nuclei  and 
cerebellum  ;  in  one  of  the  lenticular  nuclei  alone  ;  and  in  another 
of  the  right  cortical  motor  area.  There  certainly  seemed  to  be,  as 
others  have  observed,  a  greater  tendency  to  depression  where 
there  was  right-sided  cerebral  disease.  In  one  of  the  six  cases,  a 
hypochondriacal  general  paralytic,  the  lesions  Avere  very  extensive, 
there  being  adhesions  all  over  both  hemispheres.  Tavo  general 
paralytics  vvdth  expansive  delusions  had  no  adhesions  over  the 
occipital  lobes,  the  macroscopical  lesions  being  confined  to  the 
frontal,  temporal,  and  anterior  part  of  the  parietal.  It  is  right 
to  state  that  the  hypochondriacal  general  paralytic  suffered  from 
aortic  aneurism. 

Suicidal  Tendency. 

There  were  three  cases  with  suicidal  tendency.  In  one  there 
was  extensive  right  cortical  disease  with  membranous  adhesions 
over  the  occipital  lobe,  the  left  hemisphere  being  normal.  A 
second  case  had  disease  of  both  lenticular  nuclei  and  membranous 
adhesions  on  the  inferior  surface  of  the  occipito-temporal  regions 
(right  and  left)  and  cerebellum.  The  third  in  whom  the  tendency 
was  very  strong,  had  adhesions  over  both  occipital  lobes  with 
numerous  dark  points  in  the  Avhite  substance  of  these  lobes,  and 
no  other  lesion. 

SiTOPHOBIA  AND   ANOREXIA. 

The  last  mentioned  siiicidal  patient  absolutely  refused  food. 
Another  patient  with  adherent  arachnoid  over  the  occipital  lobes 
and  many  dark  points  in  their  white  substance,  took  food  very 
unwillingly  and  sparingly,  as  did  another  ^\\th  softening  of  the 
posterior  extremity  of  both  thalami.  Terrier  observed  refusal  of 
food  in  most  of  the  monkeys  from  which  he  had  removed  the 
occipital  lobes,  though  defective  vision  or  smell  may  have  had 
something  to  do  with  this  phenomenon.  It  is  quite  possible, 
however,  that  the  occipital  lobes  subserA^e  other  functions  besides 
those  of  vision  or  other  sense,  just  as  the  so-called  motor  spheres 
subserve  more  than  one  function ;  and  indeed  this  is  very 
probable  considering  the  eight-layered  formation  of  the  occipital 
cortex. 


216  pathology. 

Erotic  Tentjency  and   Loss  or  Ab->exce   of   Sexual 
Desire. 

Ferrier  noticed  strong  sexual  desire  in  one  of  the  monkeys 
from  which  he  had  removed  both  occipital  lobes.  Combette's 
patient  Tvith  congenital  absence  of  the  cerebellum  was  a  nympho- 
maniac. A  patient  of  mine,  a  female  epileptic,  had  a  Yevy  strong 
erotic,  or  more  correctly  sjoeaking,  nymphomaniacal  tendency ; 
there  was  an  extensive  superficial  brown  discoloration  of  one 
hemisphere,  and  a  destructiAe  lesion  of  the  inner  and  upper  part 
of  the  opposite  occipital  lobe  encroaching  on  the  parietal.  A 
paralytic  (and  epileptic)  idiot,  aged  19,  with  small  cerebrum 
and  large  cerebellum  showed  no  signs  of  pubertj^,  and  his  genital 
organs  were  infantile.  In  the  third  stage  of  general  paralysis, 
that  is  to  say,  when  the  cerebral  cortical  cells  are  extensively 
degenerated,  sexual  desire  and  sexual  power  are  comjDietely  lost. 
The  loss  of  sexual  desire  has  been  mentioned  by  some  observers 
(Boeck,  Le  Bceuf,  etc.)  as  the  most  marked  or  only  phenomenon 
after  the  removal  of  the  cerebrum  in  dogs  and  pigeons  (especially 
the  latter),  if  the  animals  can  be  kept  alive  through  the  drowsy  and 
irritable  stages.  Impressions  from  the  sensitive  sui^faces  of  the 
genital  organs  are  probably  received  by  the  cerebral  cortical  cells 
at  the  posterior  part  of  the  cutaneous  or  tactile  area,  a  region 
contiguous  to  the  Adsual,  auditory,  and  probably  the  olfactory 
and  gustatory  ai-eas,  and  possibly  overlapped  by  some  of  them. 
Hence  the  oliactory  and  gustatory  hallucinations  in  masturbatory 
insanity,  the  olfactory  and  tactile  in  insanity  caused  by  ovarian 
disease,  the  olfactory,  auditory,  and  visual  hallucinations  and 
illusions  in  mastiu-batory  paranoia.  Sexual  desire  may  be  aroused 
from  -without  by  impressions  made  upon  the  special  sense  areas, 
or  upon  the  sexual  area. 

The  other  symptoms  accompanied  lesions  which  varied  ex- 
ceedingly. 

D.—LESIOXS    OF   NOX-NERVOUS    ORGANS  AND 
TISSUES. 

Heart. — YahTdar  disease,  with  or  without  hypertrophy,  is 
frequently  found  in  organic  dementia  and  organic  melancholia. 
Obstructive  vahTdar  disease  is  often  seen  in  simple  and  hypo- 
chondriacal melancholia ;  dilatation  with  irritability  of  the  organ 
in  chronic  mania  ;  fatty  degeneration  in  dementia  (Bucknill  and 
Tuke).  The  muscular  fibres  of  the  heart  are  granular,  and  there 
may  be  chronic  endocarditic  lesions  in  chronic  alcoholic  insanity 
( Bra ).      The  arterial  system  is  atheromatous  in  the  same  disease. 

Lf  XGS.— In  phthisical  insanity  they  become  sooner  or  later 
affected  if  not  already  disease-d.      All  chronic  lunatics  are  prone 


PATHOLOGY.  217 

to  lung  disease,  especially  pneumonia.  Suspicious  monomaniacs 
are  peculiarly  liable  to  phthisis  (Clouston).  In  most  cases  these 
diseases  are  not  revealed  by  subjective  symptoms,  cough  being 
frequently  absent,  and  there  being  frequently  no  complaint  of  pain 
or  discomfort  on  the  part  of  the  patient.  Often  there  is  very  little 
dyspnoea.  Sometimes  patients  "will  cough  in  quiet  intervals,  but 
not  during  maniacal  excitement.  Some  pallor,  emaciation,  weak- 
ness, singly  or  combined,  may  be  the  only  indication  of  pulmonary 
disease.     Chronic  catarrh  of  bronchi  in  chronic  alcoholic  insanity. 

Stomach  and  Intestines. — Dyspepsia  is  frequently  met 
with.  In  chronic  alcoholism  the  coats  of  the  stomach  are 
thickened  and  the  glands  hypertrophied.  In  chronic  insanity 
the  large  intestines  are  often  displaced.  The  most  common  dis- 
placement is  that  of  the  transverse  colon  to  the  lower  part  of  the 
abdomen  (Bucknill  and  Tuke,  Spitzka,  etc.).  Foreign  substances 
are  frequently  found  in  the  stomach  and  intestines.  Dysentery 
and  diarrhoea  are  somewhat  frequent  in  the  chronic  insane. 

Liver. — Maybe  sclerotic  or  steatotic  in  chronic  alcoholic  insanity. 

Spleen. — Usually  small  in  chronic  insanity  (Bucknill  and 
Tuke);  hypertrophied  and  soft  in  chronic  alcoholic  insanity  (Bra). 

Kidneys. — Usually  small  contracted  kidney  (interstitial  nephri- 
tis) in  insanity  of  chronic  Bright's  disease.  Sometimes  cirrhosis 
and  parenchymatous  nephritis  in  chronic  alcoholic  insanity  (Bra). 

Bladder. — Congested  in  chronic  alcoholic  insanity. 

Uterus  and  Ovaries. — Congestion,  displacements,  false  cor- 
pora lutea,  cysts,  atrophy  of  ovaries,  tumovurs.  In  a  case  of  mine 
(melancholia  with  auditonj  hallucinations),  Avithout  visible  cerebral 
lesion,  there  were  several  small  tumours  attached  to  these  organs. 
(See  "  Morbid  Anatomy  of  Symptoms.") 

Thyroid  Gland. — Frec|uently  enlarged  in  cretinism  and 
nearly  always  in  insanity  from  exophthalmic  goitre.  Diminished 
in  insanity  from  myxoedema. 

Blood. — Diminution  of  red  globules,  and  increase  of  white 
in  anaemic  insanity,  chronic  alcoholic  insanity,  lactational  insanity. 
(See  "  General  Paralysis.")  Deficiency  in  haemoglobine  and 
haemacytes  progressing  with  age  in  dementia.  Deterioration 
also  in  masturbatory  insanity,  general  jDaralysis,  and  epileptic 
insanity,  and  after  prolonged  excitement.  It  improves  with 
mental  recovery  (McPhail,  "  Jour.  Ment.  Sci."). 

Skin. — Bedsores  or  asthenic  gangrene  are  liable  to  occur  in 
general  paralysis  and  organic  dementia.  The  skin  may  be  picked 
into  sores  by  the  patient.  Bullous  eruptions  are  sometimes  present. 

Muscles. — Fatty  degeneration  in  chronic  alcoholic  insanity. 
Von  Sass  has  found  extensive  atrophy  of  the  fibres  in  paralysis 
agitans  ("Jour.  Xerv.  and  Ment.  Dis.,"  Sept.,  1891). 


218  PATHOLOGY. 

Eaes. — One  or  both  may  be  swollen  from  otlisematoma, 
or  contracted  or  shrunken  as  a  consequence  of  that  affection. 
The  auricle  may  be  mal-formed  in  the  degenerative  insanities  and 
in  criminals,  or  present  the  Dar'svinian  tubercle  on  its  postero- 
superior  border. 

Hair. — The  chronic  insane  seem  to  be  less  prone  to  baldness 
than  sane  persons  of  the  same  age,  but  liable  to  become  pre- 
matiuely  gray.     The  hair  often  becomes  dry  and  rough. 

Boxes. — The  bones  are  abnormally  brittle,  especially  in  general 
paralysis.  They  are  liable  to  be  affected  with  osteo-malacia. 
Walsh  ("Lancet,"  July  25th,  1891)  describes  four  cases  of 
delusional  and  hereditary  insanity  with  osteo-malacia  and  cardiac 
vah-ular  disease.  The  osteo-malacia  was  symptomatised  by 
kyphosis  and  tendency  to  fracture. 

PATHOLOGY  AND  PATHOGEXESIS. 

The  highest  powers  of  the  microscope  and  the  latest  discoveries 
in  histological  method  do  not  enable  the  observer  to  find  anything 
in  the  central  nervous  sj^stem  but  cells  and  their  processes 
(A.  Hill,  "Brit.  Med.  Jour.,"  Jidy  4th,  1891).  Some  of  the 
processes  are  long,  and  are  called  fibres.  Others  "  branch  until 
they  are  lost  in  what  seems  to  be  a  comm.on  homogeneous  groimd 
substance."  These  cells  of  the  cerebral  cortex  are  of  various 
shapes  and  sizes,  and  in  the  adult  are  arranged  in  definite  layers. 
Over  the  greater  part  of  the  cortex  these  laj^ers  are  five  in  number 
(see  Meynert's  "  Psj^chiatrie,"'  I.  Halfte,  Bau  der  Grosshirnrinde, 
etc. ;  Hugenin's  "  AUgemeine  Pathologie  der  Krankheiten  des 
Xerven  Systems,"  I.  Theil,  p.  229,  et  seq.,  etc.)  Meynert,  Bain, 
and  most  authors  believe  that  these  cells  receive  and  register 
external  impressions,  and  by  intercommunication  form  idea- 
apparatus.  Mej^nert  ("Bau  der  Grosshirnrinde  und  seine 
ortliche  Verschiedenheiten")  has  roughly  estimated  the  number 
of  the  cerebral  cortical  cells  at  612,112,000  or  more;  Bain 
("Mind  and  Body'')  at  about  1,200,000,000  with  say  four 
times  as  many  association  fibres  ;  and  as  the  most  richly  endowed 
brain  does  not  possess  200,000  ideas,  there  are  manifestly  cells 
and  fibres  sufficient  and  to  spare  for  the  formation  of  idea-apparatus. 
For  these  purposes  the  cells  are  connected  with  the  organs  of 
special  sense  and  other  parts  of  the  body  hj  means  of  the  fibres 
of  the  system  of  projection,  and  with  other  cells  near  or  at  a 
distance  by  the  fibres  of  association  (Meynert).  In  certain 
positions  (to  be  mentioned  below)  some  of  the  cells  are  connected 
with  efferent  fibres  communicating  ultimately  with  the  fibres  of 
muscles  through  the  intervention  of  spinal  motor  cells.     Besides 


PATHOLOGY.  219 

the  intercommunication  between  cells  of  different  convolutions 
far  and  near  by  means  of  the  arciform  fibres  or  fibrse 
propriae,  the  cerebral  lobes  are  connected  with  each  other  by 
bundles  of  fibres  called  "association  bundles."  The  central 
ganglia  are  connected  by  means  of  projection  fibres  with 
the  cortex ;  the  convolutions  of  the  cortex  of  one  hemisphere 
are  connected  by  means  of  commissural  fibres  (corpus  callosum) 
with  the  corresponding  convolutions  of  the  opposite  hemisphere 
(though  this  is  denied  by  Hamilton)  ;  and  the  cerebrum  and 
cerebellum  are  connected  by  several  bands  {vide  infra).  These 
essential  parts  of  the  mind-tissue  are  supported  by  connective 
tissue  (neuroglia),  nourished,  especially  the  cells,  by  a  copious 
blood  supply,  and  drained  by  wide  lymphatic  vessels  (peri- 
vascular lymph  spaces).  The  eff'ects  of  the  quality  of  the 
blood  supplied  to  the  cerebral  cortex  are  seen  in  intoxications, 
slow  mineral  poisoning,  chlorosis,  etc.  With  regard  to  the 
quantity  of  blood  Mendel,  Fiirstner,  and  Kousnezoff  found,  after 
the  establishment  of  artificially  produced  hyperasmia,  the  chief 
changes  to  be  "  hypertrophy  of  connective  tissue  of  the  vessels 
and  neuroglia,  and  degeneration  of  the  cells  and  nerve  fibres  " 
(Batty  Tuke,  "A  Plea  for  the  Scientific  Study  of  Insanity," 
"Brit.  Med.  Jour.,"  May  30th,  1891).  In  a  general  way 
these  are  the  changes  found  in  general  paralysis,  chronic 
alcoholism,  chronic  epilepsy,  chronic  mania,  terminal  dementia, 
etc.  (see  "  Morbid  Anatomy ").  Occasionally  in  mania  and 
melancholia  terminating  fatally  at  an  early  period,  sub- 
inflammatory  products  (leucocytes,  pigment,  nuclear  prolifera- 
tions, etc.)  are  found  between  the  hyaline  sheath  and  the  muscular 
coat  of  the  vessels  of  the  superior  convolutions.  Occasionally 
there  are  evidences  of  stasis  with  distension  and  blocking  of  the 
perivascular  lymph  spaces  (Batty  Tuke,  loc.  cit.).  In  acute 
mania  the  most  constant  apjDearance  is  hypergemia,  and  in  the 
sub-acute  forms  there  are  found  the  results  of  prolonged 
congestion  (thickened  membranes,  etc.).  Meynert  found  47  per 
cent,  of  the  total  number  of  the  brains  of  maniacs  hyperasmic.  In 
patients  dying  during  the  excited  stage  of  acute  delirium,  an  intense 
hyperaemia  of  the  brain  and  its  meninges  is  constantly  found 
(Spitzka).  Meynert  in  his  classification  divides  prosencephalic 
diseases  into  anatomical,  nutritional,  and  toxic ;  the  nutritional 
diseases  (cortical  or  sub-cortical)  include  the  so-called  functional 
forms  ;  there  being  cortical  anaemia  with  sub-cortical  hypergemia 
in  depression,  and  the  reverse  conditions  in  exaltation.  Tran- 
sitory local  hyperaemia  is  physiological  and  necessary  to  the 
performance  of  the  functions  of  the  cerebral  cortex,  as  has 
been  demonstrated  by  several  observers  who  have  had  opportunities 


220  PATHOLOGY. 

of  stud^nng  cases  in  which  a  portion  of  the  skull  had  been  removed. 
Batty  Tuke  has  had  two  such  cases  under  observation,  and  he 
says  {loc.  cit.)  that  bulging  occurred  through  the  openings  during 
mental  action  ;  that  this  bulging  was  proportional  to  the  intensity 
of  mental  action,  and  steadily  increased  until  a  certain  maximum 
point  was  gained,  gradually  disapjDearing  when  the  stimulus  to 
cerebral  action  was  withdrawn.  Others  have  noticed  the  same 
phenomena,  and  the  experiments  of  Lombard  on  the  regional 
temperature  of  the  head  during  intellectual  activity  and  emotional 
excitement,  support  the  conclusions  arrived  at  by  these  observers. 
(See  "  Temperature,  Regional  of  Head,"  chap.  II.)  If  this  con- 
dition is  long  maintained  through  persistent  intellectual,  or 
emotional  activity,  the  physiological  line  may  be  passed  and 
jDathological  conditions  induced.  The  readiness  AWth  which 
some  emotions  cause  vascular  dilatation  is  seen  in  flushing  and 
blushing ;  whilst  certain  emotions  such  as  sorroAV  (Lange)  and 
fear,  cause  vaso-constriction  and  consequent  anaemia  (encephalic) 
accompanied  possibly  by  venous  hyperaemia,  and  probably 
active,  local,  cortical  hyperasmia  of  the  occipital  lobes.  The 
waste  products  of  the  action  of  the  brain  are  acid,  lactic  acid 
predominating  (Maudsley).  Eoy  found  that  the  injection  of 
acid  brain  filtrates  was  rapidly  followed  by  hypereemia.  Meynert 
("Psychiatrie")  ascribes  two  functions  to  the  cerebral  cortex,  viz., 
mentation  and  vaso-constriction  ;  when  the  first  is  active  the 
second  is  inactive  and  rice  versa.  The  process  then  is  somewhat 
as  follows :  The  cortex  receives  a  stimulus,  intellectual  or 
emotional,  through  the  special  senses  or  the  general  sensibility 
("vivid  impressions"  of  Herbert  Spencer),  aided  in  all  probability 
by  stimuli  from  other  portions  of  the  cortex  ("faint  impressions" 
of  Herbert  Spencer),  by  vaso-dilating  drugs  (alcohol,  ether,  etc.), 
by  sexual  excesses,  or  a  too  stimulating  dietary  (see  "Etiology). 
Hyperaemia,  at  first  functional,  is  induced,  but,  either  through 
the  force  of  the  cause  or  combination  of  causes,  or  through 
cortical  structural  defect  (heredity),  the  physiological  line  is 
passed,  and  the  intercommunicating  pericellular  and  perivascidar 
lymph  spaces  are  loaded  with  effete  matters  which  assist  in  main- 
taining the  hyperaemic  condition.  The  neiu'oglia  elements  become 
hypertrophied,  nourished  by  the  super-abundant  refuse  matters  ; 
and  the  nerve-cells,  strangled  by  the  increased  connective  tissue, 
degenerate,  the  condition  being  symptomatised  at  first  by  delirium 
or  mania,  and  afterwards  by  incurable  dementia.  The  cells  may 
also  degenerate  intrinsically  apart  from  the  action  of  the  neuroglia. 
In  acute  delirium  in  the  latter  stages  oedema  takes  place,  causing  the 
stuporous  condition  then  observed.  Anaemia,  caused  by  profuse 
haemorrhages,  exhausting   diseases   or  discharges,   or   starvation 


PATHOLOGY.  221 

(see  "Etiology"),  may  give  rise  to  mental  disease  througli 
defective  nutrition  of  the  cortex.  The  nuclear  elements  of  the 
cells  also  undergo  pathological  alterations,  Meynert  having  dis- 
covered proliferating  nuclei  and  also  free  nuclei  in  melancholia, 
and  nerve-cell  nuclei  with  tripartite  nucleoli  in  senility.  There 
may  be  pi-imaiy  physiological  and  pathological  changes  in  the 
cell  contents  which  the  microscope  is  as  yet  not  powerful 
enough  to  show,  or  which  require  untried  histological  methods 
for  their  discovery  ;  just  as  there  are  chemical  physiological 
processes,  of  which  we  know  little,  going  on  in  the  brain  cells 
and  fibres  synchronously  with  function,  and  pathological  chemical 
processes  of  which  we  know  less,  manifested  outwardly  by 
symptoms  of  mental  disorder.  With  regard  to  these  chemical 
alterations:  (1,)  Prolonged  activity  changes  the  reaction  of  the 
axis-cylinder  from  alkaline  to  acid  (Gamgee) ;  (2,)  Cerebral 
activity  increases  the  quantity  of  phosphates  in  the  urine  or, 
at  all  events,  it  increases  the  alkaline  phosphates,  though  Hodges 
Ward  says  it  at  the  same  time  diminishes  the  earthy  (Cranstoun 
Charles),  it  increases  the  quantity  of  the  urine  and  the  amoimt 
of  urea;  (3,)  The  cerebral  phosphorised  bodies  (kephalin, 
myelin,  etc.)  have  strong  affinities  for  the  oxides  of  lead,  copper, 
manganese,  iron,  etc.  (Thudichmn). 

The  Cell  in  its  relation  to  other  cells  of  the  Cerebrum, 
THE  Cerebellum,  and  the  Central  Ganglia. 
When  a  child  of  a  few  months  old  perceives  for  the  first 
time,  say  an  orange,  the  colour  cells  of  the  cortex  most  probably 
in  the  occipital  region  (Meynert,  Munk,  Hitzig,  Schafer,  etc.) 
receive  the  impression  from  the  retina  corresponding  to  the  colour 
orange  ;  other  cells  in  the  same  lobe  the  impression  of  roundness, 
these  cells  being  connected  by  the  arciform  fibres  ;  ganglion  cells 
in  the  f ronto-parietal  region  (Luciani,  Gowers,  etc. )  receive  the  im- 
pression of  sphericity  ( touch) ;  others  in  the  same  region  of  solidity ; 
yet  others  of  more  or  less  roughness  of  surface.  The  smell  of  the 
fruit  is  impressed  on  the  cells  of  some  of  the  convolutions  of  the 
cerebral  convexity  (Gowers) ;  or  in  or  near  the  cornu  ammonis 
and  hippocampus  (Luciani).  If  the  child  lifts  and  bites  the 
orange  the  impression  of  weight  and  resistance  will  be  received 
in  or  near  the  central  convolutions  (Meynert,  Gowers,  Luciani). 
An  impression  Avill  also  be  produced  (according  to  Terrier)  on  the 
cells  of  the  lowest  part  of  the  middle  temporo-sphenoidal  convo- 
lution, but  more  probably  on  some  of  the  cells  of  the  convexity 
or  in  the  hippocampal  region.  When  afterwards  the  child  hears 
the  word  "orange"  associated  with  the  object  which  has  produced 
in  him  pleasant  or  unpleasant  sensations  as  the  case  may  be, 


222  PATHOLOGY. 

communication  is  made  by  means  of  the  longer  association  fibres 
between  the  above-mentioned  cortical  regions  and  the  temporal 
lobe  (Munk,  Meynert),  and  unused  cells  there  are  added  to  the 
network  (Ferrier  limits  the  perceptive  centre  for  the  sense 
of  hearing  to  the  upper  part  of  the  superior  temporal  convolu- 
tion) ;  and  Avhen  the  child  himself  begins  to  use  the  word,  cells  in 
the  opposite  wall  of  the  fissure  of  Sylvius,  viz.,  the  posterior  part 
of  the  inferior  frontal  convolution  (Broca,  Ferrier).  Meynert  be- 
lieves that  the  centres  for  psychical  speech  are  situated  in  the  walls 
of  the  Sylvian  fossa,  and  in  the  walls  he  includes  the  island  of  Reil. 
This  whole  network  of  cells  and  fibres  represents  the  child's  idea 
of  an  orange.  As  he  grows  older  many  more  facts  (habitat, 
varieties,  botanical  characters,  etc.,  etc.)  are  added  to  the  first 
simple  idea  apparatus,  and  abstract  ideas  (fragTance,  acidity, 
natural  order,  etc.)  are  formed. 

If  after  a  lamb  has  been  seen  for  the  first  time  and  heard 
to  bleat,  the  sound  of  bleating  is  heard  when  the  lamb  is  hidden 
from  view,  the  appearance  of  the  lamb  will  be  re-called 
(Meynert).  When  the  infant  touches  a  part  of  his  own  body  he 
feels  the  sensation  of  touching  as  well  as  that  of  being  touched 
(AVundt,  Meynert).  When  he  moves  his  limbs  he  feels  the  effort 
and  sees  the  efi'ect ;  when  he  cries  he  has  at  the  same  time 
sensations  of  muscular  effort.  In  this  way  he  begins  to  dis- 
tinguish impres.sions  received  from  his  own  body  from  those 
received  from  his  environment.  A  nucleus  of  the  indi\'iduality, 
the  jDrimary  ego,  is  formed  (Meynert).  But  there  is  a  secondaiy 
ego  constituted  by  the  most  frequently  repeated  perceptions 
of  the  outer  world,  and  the  most  often  repeated  memories, 
particularly  those  associated  mth  the  emotions.  This  secondary 
ego  embraces  perceptions  of  intimate  persons,  wealth,  objects  of 
ambition,  patriotism,  etc.,  etc.  (Meynert). 

The  convolutions  and  lobes  of  opposite  sides  are  intimatel}^ 
associated  through  the  fibres  of  the  corpus  callosum  (Meynert, 
"Psychiatrie"),  the  influence  of  the  left  hemisphere  as  a  rule 
preponderating  o^^^ng  to  the  universal  prevalence  of  right- 
handedness.  Each  so-called  centre  has  a  mde  cortical  area 
surrounding  it  to  receive  fresh  impressions,  or  to  replace  in  time 
disused  portions.  Goltz  found  that  removal  of  any  part  of  the 
hemisphere  caused  dimness  of  vision,  but  that  the  injury  to  sight 
was  greater  when  the  occipital  lobes  were  removed  than  when 
the  frontal  lobes  were  taken  away.  The  mere  visual  defect  soon 
passed  away;  the  animal  coulcl  see  objects,  but  it  could  not 
distinguish  a  stone  from  a  piece  of  meat  by  sight  alone.  The 
cortical  "vdsual  acquisitions  or  memories  had  entirely  disapjjeared. 
The  animal  suffered  in  fact  from  mental   blindness    ("Brain" 


PATHOLOGY.  223 

vol.  vi.,  p.  153).  Stimuli  applied  to  the  motor  regions  of  the 
cortex  of  the  new-born  infant  do  not  provoke  muscular  move- 
ments as  in  the  adult  (Soltmann,  Meynert).  The  movements  are 
at  first  reflex,  but  through  the  thalamus  innervation-sensations 
are  received  by  the  cells  of  the  motor  area.  Herbert 
Spencer  ("Principles  of  Psychology ")  says  the  first  dawnings 
of  intelligence  are  developed  through  the  multiplication  and 
co-ordination  of  reflex  actions.  Sucking  is  at  first  a  reflex  act 
(as  shown  by  the  fact  that  anencephalous  children  can  accomplish 
it).  But  when  the  child  sucks  during  dreamy  sleep  it  is 
a  proof  that  the  act  has  been  registered  in  the  cortex  (Meynert). 
Every  registered  image  depends  upon  impressions  received 
primarily  in  the  sub-cortical  centres.  That  is  to  say,  the  repre- 
sentative cognitions  (concrete  ideas)  and  feelings  (emotions),  and 
the  presentative-representative  (or  perceptions)  depend  upon  the 
presentative  feelings  (or  sensations)  and  the  presentative  cognitions. 
In  the  same  way  voluntary  movements  arise  out  of  reflex  actions. 
To  use  Meynert's  illustration  :  let  a  sharp  instrument  touch  the 
conjunctiva  ;  the  impression  Avill  be  conveyed  by  the  fifth  nerve 
to  its  nucleus  in  the  medulla ;  from  this  the  sub-cortical  bulbar 
centre  of  the  seventh  nerve  will  transmit  the  stimulus  to  the 
branch  of  the  facial  nerve  ending  in  the  sphincter  palpebrarum. 
There  will  be  three  impressions  registered  in  the  cortex,  viz. : — 

(1,)  The  image  of  the  sharp  instrument,  this  image  being  con- 
veyed by  the  second  nerve  and  its  continuation  to  the  occipital  lobe. 

(2,)  The  sensation  transmitted  by  the  fifth  nerve  to  its  cortical 
centre. 

(3,)  Sensations  of  innervation  conducted  through  the  thalamus 
to  the  innervation-centre  (in  the  cortex)  of  the  facial  nerve. 

These  cortical  centres  will  be  united  by  association  fibres.  If 
afterwards  a  needle  be  brought  near  the  conjunctiva  "without 
touching  it,  the  image  of  the  needle  will  revive  the  sensation  of 
pain,  and  also  the  sensation  of  innervation  of  the  facial  branch,  and 
contraction  of  the  orbicularis  palpebrarum  will  again  take  place. 

According  to  my  OAvn  observations  the  muscular  innervation- 
sensations  are  much  m.ore  intimately  connected  with  the  sense  of 
pain  than  is  the  sense  of  sight ;  at  all  events,  it  always  takes  the 
muscular  movements  to  complete  the  association.  If  an  infant  of 
nine  months  or  so  touches  the  flame  of  a  candle,  it  has  the 
impulse  to  do  the  same  thing  if  it  sees  the  candle  a  few  hours 
afterwards ;  it  stretches  out  its  arm,  but  the  instant  it  has  done  so, 
it  Avithdraws  it  quickly  vnthout  touching  the  candle.  This  woulcl 
seem  to  indicate  that  the  pain  sense  and  the  muscular  sense  areas 
are  in  close  proximity,  and  that  inhibition  is  primarily  a  function 
of  the  motor  area.      It  should  be   remembered,  however,  that 


224  PATHOLOGY. 

a  slight  sensation  of  warmth  from  the  flame  may  be  the  factor 
that  completes  the  remembrance  of  the  painful  sensation.  The 
child  on  the  next  occasion  will  not  attempt  to  touch  the  flame, 
the  visual  image  being  then  sufficient  to  warn  him. 

The  optic  thalamus  has  extensive  connections  with  the  cortex 
through  centripetal  (the  coi-tex  is  here  considered  central)  pro- 
jection fibres,  and,  mth  the  corpora  quadrigemina,  constitutes  a 
way  station  for  innervation  sensations  between  the  nerve  nuclei 
and  the  cerebral  cortex  (Meynert). 

The  nucleus  lenticularis  is  most  highly  developed  in  man  and 
apes  ;  it  is  also  well  developed  in  the  bat  and  mole.  According 
to  Meynert  it  has  special  relations  \Wth  the  movements  of  the 
upper  extremity,  as  well  as  with  the  hypoglossal  and  facial  nerves. 
Hemiplegia  results  from  destruction  of  the  prosencephalic 
ganglion,  especially  of  the  nucleus  lenticularis.  The  nucleus 
lenticularis  and  the  nucleus  candatus  are  larger  anteriorly  than 
posteriorly,  and  therefore  are  in  a  position  to  receive  more  fibres 
from  the  anterior  cortical  regions  (Meynert).  Fibres  connect  the 
thalamus  and  corpora  quadrigemina  with  the  occipital  and 
temporal  lobes  (Gratiolet,  Meynert).  The  sensory  fibres  of  the 
internal  capsule  also  enter  these  lobes.  The  anterior  commissure 
(supposed  to  be  an  olfactory  chiasm)  is  connected,  according  to 
Arnold,  with  the  cortex  of  the  temporal  lobe,  and  according  to 
Burdach  and  Meynert,  with  that  of  the  occipital  also.  In 
my  two  cases  of  anosmia  there  were  adhesions  over  both  occipital 
lobes  (vide  supra).  In  animals  Avith  a  large  olfactory  lobe  the 
nucleus  candatus  is  comparatively  largely  developed. 

According  to  Mauthner,  sleep  is  to  be  considered  as  an  evidence 
of  tiring  of  the  central  gray  matter  of  the  ventricles,  leading  to 
suspension  of  its  functions  and  intenaiption  in  the  conduction  of 
centripetal  and  centrifugal  impressions  to  and  from  the  cerebral 
cortex,  although  the  cortex  and  the  senses  are  awake.  The 
following  seems  to  me  to  be  a  more  satisfactory  explanation  of  the 
production  of  sleep  : — 

(1,)  Withdrawal  of  stimuli  from  the  cortex. 

(2,)  Consequent  functional  anaemia  of  the  cortex  {vide  supra  as 
to  mentation  and  vaso-constriction).  This  factor  is  aided  by 
dilatation  of  the  cutaneous  capillaries  by  baths,  etc.,  or  of  the 
gastro-intestinal  by  food,  etc. 

(3,)  Passive  congestion — hyperagmia  ex  vacuo — of  the  central 
ganglia,  the  venous  sinuses  at  the  base  being  very  distensible, 
and  according  to  Meynert,  increasing  or  diminishing  in  size 
according  to  the  amount  of  pressure  in  the  intra-cranial  cavity. 
The  internal  capsule  is  compressed,  and  in  part  grasped  by  the 
turgid  ganglia. 


PATHOLOGY.  225 

(4,)  The  How  into  the  distended  ventricles  ot  chc  cerebro-spinal 
fluid,  and  also  prol)al)ly  the  pressure  of  the  basal  lymphatic 
cushions,  still  further  increasing  the  pressure  on  the  ganglia, 
capsules,  and  peduncles. 

(5,)  The  acquisition  of  the  habit  of  sleep. 

This  theory  somewhat  resembles  that  of  Cappie  (Mackenzie, 
"  Jour.  Ment.  Sci.,"  Jan.,  1891),  but  he  does  not  limit  the  venous 
distension  to  the  base.  In  support  of  the  arterial  contraction  and 
venous  distension  theory  of  sleep,  he  adduces  the  fact  that  during 
sleep  the  arteries  of  the  retina  are  extremely  contracted  and  the 
veins  very  much  dilated  (Hughlings- Jackson,  Gairdner).  This 
phenomenon  is,  however,  rather  more  in  favoiu"  of  the  basal  hypo- 
thesis than  of  the  general.  The  fact  that  the  cortex  has  been  seen 
in  repeated  experiments  to  become  pale  and  sink  during  natural 
sleep  (Durham,  Hammond,  Carpenter)  proves  the  absence  of  venous 
congestion  in  the  cortex.  That  the  contraction  of  the  arterioles 
per  se  is  not  the  cause  of  sleep  is  disproved  by  the  frecpent  occur- 
rence of  insomnia  in  persons  with  contracted  arteries  and  pulse  of 
high  tension.  But  it  may  be  said  that  this  disproves  the  vascular 
theory  altogether.  Not  so,  however,  for  it  is  not  the  contraction  of 
the  arteries  that  induces  sleep,  but  this  contraction  followed 
by  the  compensatory  basal  venous  in-flow,  so  that  if  the  arteries 
are  already  contracted  the  latter  process  cannot  take  place. 
Vaso-dilating  drugs,  such  as  sulphonal,  mercury,  etc.,  enable  this 
process  to  take  place.  The  accumulation  of  lactic  acid,  etc.,  in 
the  blood,  as  a  result  of  mental  or  bodily  exercise,  has  the  same 
effect  in  the  physiological  condition.  Small  clots  in  or  on  the 
central  ganglia,  or  at  the  base  compressing  them  or  the  pons, 
cause  coma  more  readily  than  larger  ones  on  the  vertex. 
Bristowe  reports  four  cases  of  tumour  compressing  the  central 
ganglia,  and  in  three  of  them  drowsiness  was  a  prominent 
symptom.  J.  Hutchinson  another  in  which  the  patient  slept 
better  than  he  used  to  do.  Gowers  ("Quain's  Diet.")  speaks  of 
the  frequent  occurrence  of  rupture  of  the  cerebral  arteries  during 
sleep,  and  in  the  same  article  he  says  the  most  frequent  seat 
of  cerebral  hsemorrhage  is  "  the  corpus  striatum  and  the  region 
just  outside  it : "  "  nearly  half  the  intra-cerebral  haemorrhages 
are  in  this  situation."  The  effects  of  effusions  varying  with 
their  position  ;  the  effects  of  habit  in  infancy  ;  dreaming,  somnam- 
bulism, stupor,  hypnotism,  insomnia  and  somnblence,  are  explicable 
on  this  hypothesis.  (See  below,  "Connections  of  the  Cere- 
bellum," etc.). 

Stupor  is  symptomatic  of  cerebral  oedema  and  may  vary  from 
mere  intellectual  numbness  (light  stupor)  to  cessation  of  mental 
action    (Gedankenstillstand,  Meynert)  for  the  time  being  (deep 

15 


226  PATHOLOGY. 

Stupor).  In  partial  coma  and  in  light  stupor  the  patient  can  be 
roused  momentarily  by  shouting,  etc.,  but  the  resulting  cortical 
hypersemia  cannot  of  course  cause  removal  of  pressure  from  the 
capsules  and  peduncles  as  in  sleep,  and  the  patient  therefore 
relapses  into  his  comatose  or  stuporous  condition.  With  greater 
intra-cranial  pressure  the  only  responses  to  stimulation  are  reflex 
(conjunctival  reflex,  etc.),  and  in  profound  coma  the  only 
reflex  left  may  be  the  respiratory,  and  even  this  may  succumb  to 
the  pressure  encroaching  on  the  lower  regions  of  the  medulla. 

Morselli  gives  as  the  exciting  causes  of  insomn-a  : — 

(1,)  Cerebral. — Hypertemia,  meningitis,  encephalitis,  tumours  ; 
psychical  causes,  grief  or  other  emotions,  fear,  etc.,  etc. 

(2,)  Peripheral. — Sensory  stimidi,  physical  pain,  neuralgia,  con- 
gestions, inflammations,  etc. 

(3,)  Hcernic. — Cardiopathies,  anaemia,  plethora,  chlorosis,  in- 
toxicants, poisons,  medicaments,  infections,  septicaemia,  etc. 

In  many  cases  of  mania,  in  acute  delirium,  in  the  congestive 
stage  of  general  paralysis,  the  insomnia  really  arises  from  cerebral 
hyperemia  ;  but  as  this  is  caused  by  vaso-motor  disturbances  it 
does  not  constitute  a  sufficient  indication  for  general  blood-letting. 
In  fact,  the  cases  are  not  less  numerous  in  which  insomnia  is  the 
effect  of  cerebral  anaemia,  as  in  some  cases  of  furious  mania, 
in  agitated  melancholia,  in  many  cases  of  neurasthenia  and  hypo- 
chondriasis, in  acute  hallucinatory  paranoia,  in  the  third  stage  of 
general  paralysis,  in  the  delirium  of  typhus,  in  sitophobia,  in 
protracted  convalescences  ("  Malattie  Mentali,"  jjp.  208-209). 
Morselli  terms  dreamy  sleep  paragrypnia,  and  sleep  troubled  with 
mghimares  agrypnia. 

Hais  ("Brain,"  1891)  says  uric  acid  contracts  the  arterioles 
and  causes  high  arterial  tension.  The  insomnia  thus  produced  is 
relieved  by  opium  and  mercury  and  acids,  drugs  which  diminish 
the  uric  acid  holding  power  of  the  blood. 

It  will  be  readily  understood  that  increased  or  diminished 
activity  of  the  cells,  if  carried  to  an  abnormal  extent,  Avill  affect 
the  external  manifestations  of  mind  ;  that  degeneration  of  the 
cells  will  cause  hopeless  dementia.  In  addition  to  the  cellular 
and  nuclear  alterations  already  mentioned,  Meynert  has  found 
divided  cells,  inflated  cells,  and  nuclei  with  an  abnormal  tendency 
to  gravitate  to  the  lowest  part  of  the  cells.  The  cells  of  the  fronto- 
parietal region,  particularly  the  frontal,  seem  to  be  more  concerned 
with  the  higher  mental  functions  of  the  brain  than  those  of  other 
parts,  those  regions  suffering  most  markedly  from  atrophy  in 
chronic  insanity.  Kolliker  and  others  ("Brit.  Med.  Jour." 
Supplement)  have  discovered  by  using  Golgi's  method  of 
hardening  that  what  are  most  probably  centripetal  fibres  in  the 


PATHOLOGY.  227 

cerebellum,  are  not  connected  with  cells,  so  that  the  intra-cellular 
substance  is  jDresumably  not  functionless.  Kolliker's  explanation, 
however,  is  that  these  fibres  act  on  the  cells  by  actual  contact, 
and  that  these  bodies  then  transmit  the  stimuli  to  the  centrifugal 
fibres  arising  from  them. 

Unequal  action  of  the  cells  and  fibres  of  the  various  regions  of 
the  brain  will  also  cause  mental  disturbances.  This  may  be 
brought  about,  amongst  other  causes,  by  vascular  and  vaso-motor 
alinornialities.  Any  interference  with  the  fil)res  connecting  the 
thalamus  with  the  cortex,  or  lesion  of  the  thalamus,  will  cause, 
through  lack  of  or  disturbance  of  innervation-sensations,  delusions 
as  to  the  position  of  the  extremities,  forced  positions,  sensations 
of  falling  down  abysses,  etc.  (Meynert). 

Connections  of  the  Cerebellum  with  the  Cerebrum. 

As  will  be  seen  beloAv,  these  are  very  intimate  and  Avould  seem 
to  indicate  that  the  cereljellum  has  other  functions  besides 
assisting  in  co-ordinating  muscular  movements  and  in  the  main- 
tenance of  bodily  equilibrium.  Herbert  Spencer's  hypothesis  is 
that  the  cerebellum  is  an  organ  of  doubly-compound  co-ordination 
in  lipoxe,  just  as  the  cerebrum  is  in  time ;  the  former  being  con- 
cerned with  co-existent,  the  latter  with  sequential  impressions 
and  acts.  Langwieser,  in  a  paper  entitled  "  Zur  Physio- 
logischen  Erklarung  des  Bewusstseins  "  ("  Allgemeine  Zeitschrift 
fiir  Psychiatrie,"  Band  41,  Heft  1,  1884),  advanced  the  theory 
that  the  cerebellum  is  the  organ  of  consciousness  and  of  the 
ego  ;  not  alone,  but  in  conjunction  with  the  portion  of  the 
cerebrum  with  which  it  is  co-operating  for  the  time  being. 
According  to  this  view  the  cerebellum  fmthers  (in  the  cerebral 
cortex)  whatever  subject  interests  it  most,  and  other  subjects 
must  wait.  Langwieser  arrives  at  this  conclusion  because  the 
cerebellum  distinguishes  our  own  movements  from  those  of  oui- 
environment.  Consciousness  commences  with  the  ability  to  dis- 
tinguish our  own  movements  from  those  of  our  surroundings. 
Rotatory  movements  take  place  when  one  half  of  the  cerebellum 
of  an  animal  is  injured.  These  movements  take  place  because 
the  animal  is  afraid  one  side  will  fall  away,  as  it  feels  like  a 
foreign  body  to  it.  In  men  with  degeneration  of  the  cerebellum 
the  ground  seems  to  be  flying  away  from  their  feet,  and  there 
is  staggering  gait.  An  unconscious  movement  of  the  eyes,  or  an 
unaccustomed  unnoticed  movement  of  the  body,  will  cause  giddi- 
ness ;  there  is  confusion  as  to  whether  the  movement  is  of  one's 
own  body  or  of  the  surroundings  ;  the  cerebellum  is  at  fault. 

Without  suliscribing  to  the  theory  that  the  cerebellum  is 
absolutely  necessary  to  consciousness    (this  being  probably  the 


228  PATHOLOGY, 

})Otentiality  of  any  group  or  groups  of  cerebral  cortical  cells  plus 
a  stimulus  from  the  special  senses,  the  general  sensibility,  or 
cortical  cells  already  conscious),  facts  taken  from  comparative 
anatomy,  embryolog}',  human  anatomy,  physiology,  pathological 
anatomy,  and  clinico-pathology,  indicate  that  this  organ  (the 
cerebellum)  takes  an  important  place  in  the  encephalic 
mechanism. 

In  fishes  its  form  is  simpler  (consisting  merely  of  tAvo  halves 
and  having  the  appearance  of  a  single,  undivided  organ)  than  in 
any  of  the  vertebrata,  and  smaller  except  in  the  single  instance  of 
the  shark,  a  cartilaginous  fish  which,  as  well  as  being  one  of  the 
largest,  is  also  one  of  the  most  active  and  intelligent  of  the  Avhole 
class  pisces.  In  birds  it  consists  of  a  large  median  and  two 
very  small  lateral  lobes.  In  marsupials  it  still  consists  principally 
of  the  median  lobe,  the  lateral  lobes  being  mere  small  appendages. 
In  the  bat  Avith  active  and  A^aried  movements,  the  cerebellum  is 
very  large,  but  this  is  OAAang  to  the  size  of  the  middle  lobe. 
Kising  in  the  scale  the  lateral  lobes  become  more  developed  until 
in  the  cat  and  dog  there  is  a  marked  increase  in  their  size, 
and  in  the  marine  cetacea  (porpoise,  dolphin,  etc.)  this  is  still  more 
marked.  The  dolphin  evinces  rare  docility  and  intelligence,  the 
porpoise,  striking  curiosity.  In  the  quadrumana  this  develop- 
ment of  the  lateral  lol)es  is  very  great,  and  in  man  the  middle 
lobe  becomes  a  relatively  diminutive  structure  (Charlton  Bastian, 
"  The  Brain  as  an  Organ  of  Mind  "). 

Meynert  says  the  larger  the  animal  the  heavier  the  cerebellum 
in  proportion  to  the  rest  of  the  encephalon.  He  mentions  the 
elephant  as  an  extreme  instance  of  this  relationship,  the  cere- 
belkim  here  forming  nearly  a  fourth,  by  Aveight,  of  the  AA'hole 
encephalon.  But  the  elephant  is  noted  for  sagacity  as  Avell  as  for 
size,  and  is  possessed  of  an  efficient  and  unique  prehensile  organ. 
In  the  intra-uterine  period,  according  to  Flechsig,  the  medullary 
sheaths  appear  first  in  the  columns  of  Goll  and  Burdach ;  then  in 
the  anterior  columns  of  the  cord  ;  next  in  the  medulla  oblongata, 
except  the  pyramids ;  then  in  the  medullary  substance  of  the 
central  lobe  of  the  cerebellum,  folUnoid  hij  tluif  of  the  lateral  lobes. 
The  Avhite  stibstanoe  of  the  cerel:)ral  frontal  lobes  does  not  appear 
until  some  time  after  birth,  and  does  not  Ijecome  as  A\'hite  as  in  the 
adult  until  the  end  of  the  fourth  month  (Flechsig,  Meynert). 

The  cerebellum  of  the  ncAA^-born  child  onl}^  Aveighs  about  half  as 
much  relatively  to  the  cerebrum  as  does  that  of  the  adult,  and  the 
disproportion  may  be  even  greater  (Meynert,  Sharpey,  Bastian). 
Meynert  gives  the  folloAving  ratios  :  (1,)  Cerebral  mantle  ;  (2,) 
Islands  of  Reil  to  cord;  (3,)  Cerebellum,  resj)ectively ;  in  the 
adult,  79 :  10-5:10 -5  ;  in  the  neAA^-born  child,  83:11:5. 


PATHOLOGY.  229 

According  to  Flechsig,  quoted  by  Gowers  in  "  Diagnosis  of 
Brain  Diseases,"  fibres  pass  from  the  prefrontal  lobe  to  the  lateral 
and  posterior  parts  of  the  cerebellum,  degenerating  downwards  ; 
others  pass  chiefly  from  the  upper  surface  of  the  middle  lobe 
of  the  cerebellum,  and  running  partly  beneath  the  lenticular 
nucleus  and  partly  between  it  and  the  corpus  geniculatum  ex- 
ternum enter  the  temporo-sphenoidal  and  occipital  lobes  without 
passing  through  the  internal  capsule.  These  degenerate  upwards. 
Other  fibres  run  from  the  caudate  nucleus  to  the  cerebellum, 
degenerating  downwards  ;  and  yet  others  from  the  cerel)ellum  to 
the  lenticular  nucleus,  degenerating  upwards  (probably).  These 
fibres  connect  the  corpus  striatum  Avith  the  opposite  half  of  the 
cerebellum  through  the  pons.  The  candate  fibres  enter  the  cere- 
bellum by  the  middle  peduncles,  and  the  lenticular  by  the 
superior.  The  optic  thalamus  also  receives  fibres  from  the 
superior  peduncle  of  the  cerel>ellum.  The  fronto-ccrebellar  fibres 
only  degenerate  as  far  as  the  pons,  the  degeneration  being  there 
arrested,  as  usual,  by  the  gray  matter.  These  and  the  temporo- 
cerebellar  and  occipito-cerel^ellar  fibres  are  absent  in  congenital 
absence  of  the  cerebellum,  and  the  corpus  striatum  is  reduced  to 
one  third  of  its  ordinary  size.  Gowers  {op.  (it.)  considers  that 
these  extensive  connections  with  regions  of  the  cerebrum,  Avhich 
are  not  motor  and  only  sensory  in  limited  area,  warrant  the 
revival  of  the  old  theory  that  the  cerebellum  plays  an  important 
part  in  intellectual  processes. 

Visceral,  as  well  as  (special)  sensory  nerve  fibres,  have  been 
traced  to  the  cerebellum.  According  to  Eibot,  the  former  play 
an  important  role  in  the  formation  of  the  ^' personnalite." 

The  removal  of  the  cerebellum  in  animals  has  given  rise  to 
affections  of  equilibration,  but  no  experiments  have,  I  think, 
been  recorded  in  which  monkeys  or  dogs,  previously  intelligent 
and  docile,  were  tried  as  to  their  capability  of  learning  new 
tricks  after  the  removal  of  the  cerebellum,  or  of  its  lateral  lobes. 
Nothnagel  has  proved  that  it  is  the  middle  lobe  of  the  cerel>ellum 
that  is  connected  with  the  maintenance  of  equilibrium,  the  lateral 
lobes  having  been  removed  experimentally  and  by  disease  Avithout 
any  consequent  loss  of  motor  co-ordination  or  equilibration 
(GoAvers). 

Weir  Mitchell  found  that  pigeons  could  Avalk  steadily  many 
months  after  the  cerebellum  had  been  destroyed,  though  at  first 
they  could  not  do  so.  He  observed  "  only  feebleness  and 
incapacity  for  prolonged  muscular  exertion"  Avhen  they  had 
recovered  steadiness  in  their  movements  (Ferriei",  "The  Functions 
of  the  Brain"). 

Luciani  removed  almost  completely  the  cerebellum  of  a  dog. 


230  PATHOLOOY. 

Immediately  after  and  for  two  months  there  was  inco-ordination 
of  all  the  vohintary  movements;  the  animal  could  neither  stand, 
walk,  swim,  nor  feed  itself.  Then  the  inco-ordination  in 
swimming  disappeared  altogether.  There  was  a  special  form  of 
ataxy  of  the  other  voluntary  movements  ;  these  lacked  steadiness 
and  force,  and  there  was  a  constant  clonic  motion.  This  period 
lasted  four  months.  The  third  and  last  stage  was  characterised 
by  nutritional  failure,  and  finally  marasmus.  The  dog  lived  eight 
months  after  the  operation.  In  another  dog  he  removed  the 
sigmoid  gyri  as  well  as  the  cerebellum.  There  was  a  greater 
amount  of  paresis  of  all  the  liml)s  than  occurs  when  the  .sigmoid 
gyri  are  extirpated  without  the  cerebellum.  He  says  the 
cerebellum  "is  a  central  organ  on  which  depend  the  tone  and  a 
great  part  of  the  disposaljle  nervous  energy  of  the  motor  elements 
of  the  mitscles"  ("  Joiu\  Xerv.  and  Ment.  Dis.,"  Oct.,  1884). 

To  compare  the  above  results  with  the  remote  effects  of  removing 
the  cerebrum  {ride  supra  "Erotic  Tendency,"  etc.).  Steiner 
found  that  osseous  fishes  caught  and  ate  Avorms  the  next  day 
after  having  the  cerebrum  removed  and  the  apertixre  in  the  skull 
sealed  up  ("Brain").  Meynert  says  that  animals  (mammalian)  from 
which  the  cerebral  hemisj^heres  have  l)een  taken,  are  able  to  preserve 
their  equilibrium,  but  are  stuporous,  cataleptic  and  unconscious. 

The  cerel^ellum  is  sometimes  altogether  absent  in  idiocy 
(Hitzig,  Krafft-Ebing). 

Terrier  {op.  cit.)  mentions  a  case,  as  alread}^  stated,  recorded 
by  Combette,  in  which  this  organ  was  absent,  and  the  only 
characteristic  symptom  was  that  the  patient  frequently  fell;  yet 
he  says  on  another  page  that  she  suffered  from  nymphomania,  a 
psychical  symptom  which  is  seldom  solitary,  and  the  presence  of 
which  is  noteworthy,  as  the  removal  of  the  cerebral  cortex  in 
dogs  and  pigeons  causes  total  loss  of  sexual  desire  {dde  supra 
"Morbid  Anatom}^  of  Symptoms  ").  Terrier  also  mentions  the  case 
of  Guerin  (reported  hy  Bouillaud  and  referred  to  by  Longet  and 
Yulpian),  "  whose  cerebellum  was  found  after  death  to  be  almost 
completely  destroyed  by  disease."  He  "  still  retained  the  power 
of  co-ordination  of  movements  and  could  walk,  only  he  was 
observed  to  reel  and  totter  when  he  walked." 

Ross  ("A  Treatise  on  Xervous  Diseases,"  vol.  ii,  p.  704) 
mentions  cases  of  atrophy  of  the  cerebellum  reported  by  Combette, 
Meynert,  Pierret,  Fiedler,  Clapton,  Dugnet,  Moreau,  Lallement, 
and  Otto.  Seven  of  these  authors  observed  motor  disturbances, 
mostly  ataxic,  but  in  some  cases  there  was  slowness  of  gait  with 
frecjuent  falls,  especially  backwards.  Speech  was  temporarily  or 
permanently  affected  in  all  the  cases  with  motor  disturbance. 
Lallement  and  Otto  noticed  no  motor  disturbance.     The  latter's 


PATHOLOGY.  231 

patient  was  imj^ulsive  in  his  movements.  Analgesia  and  slight 
disturbances  of  sensibility  are  occasionally  observed. 

Foville  found  diminished  sensibility,  Renzi  impairment  of 
vision  and  hearing,  Lusanna  of  vision  only,  resulting  from 
destructive  lesions  of  the  cerebellum  (Meynert,  "Psychiatrie"). 

The  patients  of  Combette,  Clapton,  Otto,  and  Fiedler  were 
tveak-miiided,  even  idiotic,  and  Pierret's  case  suffered  from  weakness 
of  memory  (Ross,  loc.  cit.). 

In  reports  of  cases  of  adventitious  products  in  the  cerebellum, 
apathy  and  somnolence  are  often  mentioned,  but  such  cases 
should  not  have  too  much  stress  laid  on  them,  as  pressure  on 
surrounding  organs  (pons,  medulla,  veins  of  Galen,  aqueduct  of 
Sylvius,  etc.)  may  account  for  some  of  the  symptoms.  Alterations 
in  colour,  consistence,  and  size  of  the  cerebellum  are  frequently 
found  in  the  insane  without  loss  of  the  power  of  equilibration  or 
co-ordination,  where  the  absence  of  cerebral  cortical  or  ganglionic 
paralysis  allows  these  functions  to  be  tested. 

In  ten  autopsiesi  found  one  cerebral  hemisphere  markedly  lighter 
than  the  other,  the  difference  in  weight  varying  from  400  grains 
to  2102  grains,  and  in  one  case  5244  grains.  In  five  of  these,  one 
hydrocephalic  idiot  with  paralysis  and  epilepsy,  two  paralytic 
and  epileptic  idiots  and  two  organic  dements,  one  half  of  the 
cerebellum  Avas  lighter  than  the  other,  the  difference  in  weight 
varying  from  28  grains  to  246  grains,  the  lighter  half  being  on 
the  side  of  the  heavy  cerebral  hemisphere.  In  a  sixth  case 
(organic  dementia),  the  heavy  half  (right)  of  the  cerebellum  was  on 
the  side  of  the  heavy  cerebral  hemisphere  and  contained  a  dark 
hsemorrhagic  focus,  1|^  inches  long  ;  the  left  frontal  cerebral  cortex 
was  apparently  normal  although  there  was  a  small  hsemorrhagic 
focus  Avith  surrounding  softening  in  the  centre  of  the  white  substance 
of  the  lobe  posteriorly.  There  were  extensive  lesions  in  the  other 
parts  of  the  cerebrum  on  both  sides.  The  patient  was  very 
demented  and  feeble,  the  right  side  being  the  Aveaker,  and  the 
cutaneous  sensil)ility  more  diminished  on  that  side.  Vision  was 
nearly  nil,  but  there  was  double  cataract.  The  four  remaining 
cases,  two  organic  demerits,  one  epileptic  idiot,  and  one  general 
paralytic,  had  the  two  halves  of  the  cerebellum  exactly  equal. 
In  one  organic  dement  the  destructive  lesions  Avere  confined  to 
the  temporo-sphenoidal  and  occipital  lobes,  and  in  the  other  to  the 
right  gyrus  fornicatus.  In  the  latter  case  there  Avere  also  isolated 
sclerotic  portions  in  the  cortex  of  both  hemispheres.  The  former 
case  Avas  extremely  demented,  and  there  Avas  general  Aveakness  Avith 
paraplegia.  In  the  latter  there  Avere  extreme  dementia,  complete 
left  hemiplegia,  left  hemiansesthesia,  twitching  of  muscles  of  left 
arm  and  leg,  epileptic  seizures,  dilatation  of  right  pupil,  visual 


232  PATHOLOGY. 

hallucinations,  cerebral  vomiting  on  one  occasion,  no  aphasia, 
no  contractions.  The  idiot's  left  hemisphere  was  shorter  than 
the  right,  the  left  temporo-sphenoidal  lobe  smaller  and  harder  than 
its  fellow,  and  the  left  precuneus  very  small  :  both  occipital  lobes 
had  a  constricted  appearance,  but  there  were  no  special  lesions  of 
the  frontal  lobe  on  either  side.  The  right  limbs  (especially  the 
arm)  Avere  shorter  and  thinner  than  the  left.  The  right  arm  was 
paralysed  and  contracted,  the  right  leg  weak  but  not  contracted. 
As  to  intellect  the  patient  ranked  last  but  one  of  the  four  idiots. 
In  the  general  paralytic  the  right  cerebral  hemisphere  was  800 
grains  lighter  than  the  left ;  the  arachnoid  was  ojoaque  and  adherent 
everywhere  except  at  the  posterior  part  of  the  right  F^  encroaching 
on  F'',  where  an  effusion  formed  a  puff}^  enlargement ;  no  softening 
or  other  focal  lesion ;  floor  of  fourth  venti^cle  sahU.  The  patient 
had  suffered  from  complete  left  hemiplegia,  and  had  had  the 
typical  general  paralytic  speech. 

Eeverting  to  the  five  cases  showing  crossed  atrophy  (or  rather, 
perhaps,  arrested  development  in  the  idiots),  the  hydrocephalic 
idiot  (case  reported,  "Brit.  Med.  Jour."),  who  was  also  epileptic 
and  parah'tic  (right  side),  displayed  the  maximum  difference 
between  the  weights,  both  cerebral  and  cerebellar ;  there  was 
porencephalus,  only  shreds  of  the  cortex  of  the  left  hemisphere 
remaining  ;  the  right  lateral  ventricle  was  much  distended.  The 
right  arm  and  leg  were  paralysed,  contracted  and  atrophied. 
Speech  was  absent.  Perception,  memory,  emotion,  all  present. 
The  right  cerebral  hemisphere  weighed  8,074  grains,  and  the 
left  half  of  the  cerebellum  996  grains. 

Another  idiot  (epileptic),  who  also  suffered  from  brachio-crural 
monoplegia  with  conti'action,  seemed  totally  devoid  of  intellect, 
and  uttered  nothing  but  howls  and  cries.  His  right  cerebral 
hemisphere  weighed  5,386  grains,  and  his  left  only  3,284  grains ; 
the  left  half  of  his  cerebellum,  466  grains,  and  the  right,  366  ;  all 
very  much  below  the  normal  weight ;  all  the  convolutions  of  the 
left  cerebral  hemisphere  were  much  smaller  and  paler  than  those 
of  the  right.  The  third  epileptic  idiot  (case  reported  "Jom-. 
Ment.  Sci.)  suffered  from  right  brachio-criu-al  monoplegia  ^Yith 
contracture,  and  left  crural  monoplegia  "\A-ith  contracture,  absence 
of  speech  and  nystagmus.  He  moved  his  right  arm  freely. 
He  Avas  the  most  intelligent  of  the  four  idiots.  He  was  the  only 
one  of  the  four  with  paralysis  and  contracture  of  both  lower 
extremities.  The  central  convolutions  on  the  left  side  were  exten- 
sively, and  on  the  right  slightly  atrophied  or  arrested  in  develop- 
ment. The  weights  were :  left  cerebrum,  4,598  grains;  right,  5640; 
left  cerebellum,  1078  grains;  right,  1050;  the  cerebellum  being 
larger  relatively  and  absolutely  than  in  any  of  the  other  idiots. 


PATHOLOGY.  233 

In  one  of  the  organic  dements  with  crossed  atrophy  of  the 
cerebellum,  the  left  cerebral  hemisphere  was  560  grains  heavier 
than  the  right,  of  which  F^,  F^,  and  I  R  were  softened ;  the  left 
half  of  the  cerebellum  was  60  grains  lighter  than  the  right.  Prior 
to  admission  he  had  been  alcoholic  and  suicidal.  In  the  asylum  he 
was  demented,  but  there  was  no  paralysis,  and  speech  was 
unaffected. 

In  the  other  demented  case  the  right  cerebral  hemisphere  was 
760  grains  heavier  than  its  fellow,  and  was  affected  by  yellow  soften- 
ing of  the  supra-marginal  gyrus  and  upper  or  posterior  end  of  T^ ; 
the  light  hemisphere  also  had  softening  of  T\  and  a  small  contracted 
lenticular  nucleus  containing  an  old  haemorrhagic  focus.  The 
right  half  of  the  cerebellum  was  small  ;  it  was  yellow  inferiorly, 
and  there  was  a  depression  on  the  inner  part  of  the  under 
surface  (median  lobe);  it  was  120  grains  lighter  than  the  other 
half.  Patient  was  very  demented  and  almost  completely  blind, 
but  not  deaf.  There  was  right  linguo-facial  monoplegia  with 
weakness,  bu.t  no  marked  paralysis  of  the  extremities;  vaso  motor 
paresis:  the  right  knee-jerk  was  absent;  the  right  pupil  was 
larger  than  the  left ;  there  Avas  twitching  of  the  right  facial 
muscles  ;  speech  Avas  very  defective  {cide  supra  as  to  nucleus 
lenticularis  and  facial  nerve). 

In  three  cases  of  mine,  not  included  in  the  ten  above-mentioned, 
there  was  right  hemiparesis  with  softening  of  the  right  lobe  of 
the  cerebellum. 

From  all  these  data  concerning  the  cercl^ellum,  and  from 
other  facts  mentioned  in  the  antecedent  parts  of  this  chapter, 
it  may  be  inferred  : — 

(1,)  That  its  lateral  lobes  increase  in  size  and  development 
with  the  intelligence  of  the  animal ;  if  also  Avith  the  capability  of 
performing  A^aried  and  complex  muscular  movements,  this 
inference  is  not  invalidated.  It  is  admitted  by  Sully  ("  Brain," 
1889,  Part  II.,  p.  154)  that  "attention  stands  in  a  particularly 
close  relation  to  the  process  of  motor  innervation,"  and  that 
"  there  is  a  close  affinity  betAveen  muscular  and  mental  exertion." 
"Each  is  a  variety  of  the  active  phase  of  consciousness."  Wundt 
and  Ward  "  regard  both  modes  of  activity  as  at  bottom  one." 
Bain  "seeks  to  account  for  the  whole  process  of  thought  control 
by  help  of  a  motor  process."  Motor  innerA^ation  sensations  form 
a  large  proportion  of  the  cerebral  cortical  acquisitions,  and  there- 
fore of  the  intellectual  processes.  Lombard's  experiments  on  the 
regional  temperature  of  the  head  point  to  the  motor  area  and 
the  adjoining  part  of  the  pre-frontal  lobe  as  the  most  active 
region,  both  in  intellectual  Avork  and  emotional  excitement. 
(See  chap.  II.)     The  size  also  of  the  animal  influences  the  relatiA^e 


234  PATHOLOGY. 

weight  of  the  cerebellum,  and  where  great  size  and  intelligence 
exist  in  combination,  as  in  the  elephant,  the  organ  attains  its 
maximum. 

(2,)  That  each  lateral  lobe  acts,  in  man  at  least,  in  conjunction 
with  the  opposite  prefrontal  lobe  and  central  ganglia. 

(3,)  That  its  serious  disease  or  remoA^al  entails  permanently 
increased  exertion  on  the  part  of  the  cerebrum,  as  well  as  in- 
co-ordination  and  defective  equilibration  which  are  more  or  less 
temporary. 

(4,)  That  it  assists  in  the  process  of  attention  {vide  sujora, 
function  of  the  prefrontal  lobe).  During  conscious  effort,  as  in 
forming  new  acquisitions,  whether  mental  or  muscular,  the  cere- 
brum and  cerel)ellum  act  in  conjunction  in  opening  neAv  channels, 
the  fronto-cerebellar  fibres  conveying  impulses  from  the  frontal  lobe 
to  the  cerebellum  Avhere  they  are  strengthened  and  transmitted  to 
the  occipital  and  temporal  lobes  or  to  the  basal  ganglia.  When 
actions  or  processes  of  thought  (calculation,  memory,  judgment, 
volition,  etc.)  have  been  so  frequently  rehearsed  by  the  conjoined 
organs  that  the  nervous  paths  of  association  are  opened  with 
facility,  and  Avithout  effort,  they  do  not  arouse  consciousness  ; 
they  become  automatic  (Ross,  "Brain");  are,  in  fact,  relegated 
to  the  lower  centres,  probably  the  central  ganglia,  or  are 
carried  on  by  the  unaided  motor  or  sensory  cortex,  whilst 
the  combined  frontal  and  cerebellar  cortices  attend  to  new 
ones,  or  to  the  revivification  and  completion  of  old  ones. 
Miiscular  acts,  which  have  been  frequently  performed  and  have 
become  habitual,  and  are  performed  unconsciously  or  auto- 
matically, are  carried  out  by  the  corpus  striatum,  olivary  bodies, 
and  possibly  other  ganglia  ;  or  by  the  motor  cortex  itself  Avithout 
the  prefrontal  lobe  and  the  cerebellum.  Equilibration  is  also 
accomplished  (after  it  has  lieen  learned  by  the  child)  by  these 
ganglia  Avith  the  help  of  the  thalamus  and  corpora  quadrigemina, 
the  afferent  system  being  the  fibres  from  the  muscles  and  skin, 
those  from  the  semi-circular  canals,  and  those  from  the  retina  and 
ocular  muscles  ;  the  other  organs  of  sense  are  probably  also  in 
relation  Avith  the  cerebellum.  Recent  researches  Avould  seem  to 
indicate  that  it  is  the  auditory  fibres  of  the  nerve  and  not  the 
labyrinthine  that  are  connected  AA^th  equilibration.  In  the  same 
Avay  that  the  muscular  actions  are  regulated,  and  OA^er-action  or 
under-action  avoided,  the  impulses  floAving  from  the  sensory  cells 
of  the  temporo-sphenoidal  and  occipital  lobes  are  also  regulated 
and  co-ordinated. 

(5,)  That  the  cerebellum  maintains  the  equilibrium  of  the  ego 
AAdth  reference  to  the  remaining  cerebral  acquisitions.  False 
ideas  as  to  self  and  surroundings  arise  in  consequence  of  derange- 


PATHOLOGY.  235 

ment  of  the  cereljro-cerebellar  mechanism  {vide  supra  "  Morbid 
Anatomy  of  Symptoms").  From  its  visceral,  sensory,  and 
cerebral  connections  it  probably  plays  an  important  part  in  the 
formation  of  the  personality. 

(6,)  That  the  cerebellar  cortex  is  sul^ordinate  to  the  cerebral ; 
the  central  and  basilar  ganglia  to  the  combined  cortices  ;  the 
medulla  and  cord  to  these  ganglia.  This  is  not  incompatible  with 
Hughlings-Jackson's  anatomico-physiological  division  into  highest 
(prefrontal  lobes,  etc.),  middle  (motor  and  sensory  regions),  and 
lowest  centres  of  evolution  (medulla  and  cord). 

Does  this  theory  help  to  explain  physiological  and  clinical  facts  ? 

First,  to  take  such  phenomena  as  dreaming,  sleep-walking, 
and  hypnotism  {vide  sapra  as  to  the  theory  of  sleep-production). 
The  fronto-cerebellar  fibres  run  along  the  inner  side  of  the  crus  ; 
and  the  temporo-  and  occipito-cerebellar  run  along  the  outer; 
all  superficially,  and  therefore  more  susceptible  to  the  increased 
pressure  of  the  swollen  central  ganglia  and  distended  sinuses.  In 
sound,  deep  sleep,  the  pressure  is  sufficient  to  cut  off  all  stimuli  from 
the  cerebral  cortex,  but  in  light  sleep  the  pressure  is  principally 
sustained  by  the  superficial  fibres  ;  the  cerebro-cerebellar  cortical 
communications  are  cut  ofi',  1)iit  the  deeper  fibres  convey  stimuli 
to  the  cerebral  cortex  from  the  viscera,  special  senses,  and  surface 
of  the  body,  causing  dreams.  The  absence  of  the  influence  of  the 
cerebellum  would  account  for  the  difference  between  dreams 
and  waking  thoughts ;  for  the  altered  relations  of  the  ego  and  its 
environment ;  for  the  absurdity  and  extravagance,  and  partly 
at  least  for  the  feeling  of  helplessness,  and  of  falling  down 
precipices.  Although  the  fibres  from  the  cerebellum  to  the 
cerebral  cortex  are  superficial,  those  from  the  cerelDellum  to  the 
corpus  striatum  are  somewhat  deep,  lying  between  the  pyramids 
ancl  the  substance  of  Sommering.  The  cerebellar  cortex  is  awake 
during  sleep,  and  its  communications  with  the  pons  and  motor 
tracts  are  open,  and  so  the  somnambulist  is  able  to  enact  his  dream ; 
motion  is  added  to  ideation  ;  the  temporo-  and  occipito-cerebellar 
fibres  pass  Ijetween  the  nucleus  lenticularis  and  the  corpus 
geniculatum  externum  {dde  supra). 

When  a  person  is  exposed  to  a  monotonous  visual  perception, 
e.g.,  a  bright  light  or  passes,  the  visual  cortex,  though  at  first 
stimulated,  may  become  in  suitable  weak-willed  subjects  quiescent, 
the  impressions  l^eing  relegated  to  the  corpora  <|uadrigemina 
and  geniculata ;  these  probably  become  congested  and  exert 
pressure  on  the  above-mentioned  fibres,  thus  cutting  off"  the 
cerebral  cortex  from  the  regulating  and  invigorating  influence 
of  the  cerebellum,  and  placing  the  subject  under  the  control 
of  the  hypnotiser.      Some  authors  describe  three  stages  of  the 


236  PATHOLOGY. 

hypnotic  state,  lethargic,  cataleptic,  and  somnambulic.  Hypnotic 
or  artificial  somnambulism  should  be  distinguished  from  natural 
somnambulism  (sleep-walking  or  noctambulism).  In  the  Xancy 
method  the  suggestions  of  the  operator  probably  give  rise  to  the 
circulatory  alterations  that  occur  in  drowsiness,  and  if  carried 
further,  to  those  that  occur  in  sleep.  The  first-mentioned  method 
(Braidism)  probably  acts  to  some  extent  in  the  same  way. 
The  vertiginous  sensations  and  feeling  of  falling  from  a  height 
point  to  implication  of  the  equilibration  apparatus.  Morselli 
\ap.  cit.,  p.  210)  remarks  that  these  symptoms,  along  with  a  sense 
of  ill-being,  vague  pains,  anxiet}-,  oppression,  and  accompanied  by 
paralysis  of  volition,  inability  to  cry  out,  together  Avith  the 
appearance  of  threatening  phantoms,  coi'respond  exacth^  to  ihose 
experienced  by  some  anxious  melancholiacs.  Judging  by  analogy 
the  dreamy  confusional  states  (acute  confusional  insanity,  etc.)  maj' 
be  the  sAmiptomatic  expression  of  disturbance  of  some  part  of  the 
cerebro-cerebellar  mechanism ;  such  states  are  transitory  in  sane 
persons  after  shock  or  excesses  (see  "Etiology  of  Acute  Confusional 
Insanit}'-.")  Delusions  as  to  the  identity  of  the  patient  or  those 
about  him,  also  as  to  place  and  surroundings,  may  develop  on  the 
same  basis  ;  delusions  also  as  to  one  half  of  the  body  being 
altered,  fear  of  falling  from  heights,  etc.  It  is  also  probable  that 
the  cerebellum  is  involved  in  neurasthenia  and  its  derivatives. 
Hence  the  bodily  weakness,  the  tremor  after  exertion,  the  noso- 
phobia, the  more  or  less  unsteadiness,  or  rather  uncertainty  of 
gait,  the  hampered  mental  action.  In  choreic  insanity  the  motor 
inco-ordination  extends  to  the  ideational  apparatus,  the  middle 
lobe  of  the  cerebellum,  or  the  tracts  connected  with  it,  being  first 
affected,  and  afterwards  the  lateral  lobes  with  their  tracts. 
As  Maudslej"  remarks,  the  incoherence  and  automatic  character 
of  choreic  delirium  are  striking.  Hallucinations  and  illusions 
frequently  accompany  the  delirium. 

In  acute  delirium  in  which  the  whole  encephalon  is  hypera^mic, 
there  is  absolute  incoherence  T\4th  unconsciousness,  contrasting 
strongly  "with  acute  mania  in  which  the  cerebral  cortex  alone 
is  congested. 

The  pallor  of  the  optic  disc  found  by  Clifford  Allbutt  in  mania 
does  not  necessarily  indicate  anaemia  of  the  cerebral  convexity,  as, 
according  to  Edgar  Browne,  optic  neuritis  is  caused  by  lesions, 
generall}'  diffuse  (cerebritis,  meningitis),  of  the  cerebral  base,  the 
pons,  and  the  front  of  the  cereljellum,  but  not  by  lesions  of 
the  cerebral  convexity. 

The  cerebellum  assists  the  cerebrum,  even  when  the  former 
is  healthy  in  the  organisation  of  S3^stematised  delusions. 

Accordino;   to  Ferrier  and  others   the  afferent    nerves    from 


PATHOLOGY.  237 

the  viscera  have  a  close  connection  with  the  function  of  equilibra- 
tion. They  have  also  without  doubt  great  influence  on  the 
cerebrum  (even  when  the  visceral  derangements  do  not  rise  into 
consciousness) ;  instanced  in  some  cases  of  hyi^ochondriasis,  hypo- 
chondriacal and  other  forms  of  melancholia,  and  in  gastro-enteric 
and  other  forms  of  abdominal  insanity.  Insanity  of  exophthalmic 
goitre,  insanity  of  myxoedema,  insanity  from  chronic  Bright's 
disease,  are  forms  based  on  diseases  of  bodily  organs,  and  although 
such  diseases  act  in  other  Avays  than  through  the  nerves,  yet 
their  method  of  action  must  be  partly  nervous.  Cases  of  so-called 
melancholia  arise  from  cardiac  disease.  There  are  frightful 
dreams  in  the  same  disease.  Neurasthenia  and  mental  aberration 
may  arise  from  uterine  and  ovarian  displacements  and  disorders 
Cvide  supra).  Dreams  and  delusions  about  flying  are  caused  by 
rapid  respiration,  about  suffocation  hy  laboui-ed  breathing; 
nightmares  arise  from  indigestion  or  abdominal  pressure. 

The  nutrition  of  the  brain  itself  influences,  it  goes  without 
saying,  the  sensational,  ideational  and  motor  functions  of  the 
organ.  Disagreeable  emotions  and  impairment  and  hampering  of 
function  are  thus  caused.  This  may  be  oliserved  in  some  cases  of 
melancholia,  in  primary  mental  deterioration,  in  senile  insanity, 
and  in  neurasthenia  and  neurasthenic  insanity. 

In  idiocy,  in  criminals  (moral  insanity,  imjDulsive  insanity), 
in  the  other  degenerative  forms,  paranoia,  etc.  (very  often),  there 
are  anomalies  of  the  lobes,  convolutions  and  fissures  (according  to 
Benedikt,  the  fissures  are  often  confluent  in  criminals,  the 
Rolandic  and  Sylvian,  the  occipital  and  inter-parietal,  being  those 
most  frequently  so  arranged) ;  in  these  degenerative  cases  there 
is  hereditary  neurotic  taint,  and  the  malformations  are  most 
frequently  congenital. 

With  regard  to  the  arrangement  of  the  cerebral  cells  into 
simple  and  complex  idea  apparatus,  the  symptoms  of  insanity  in 
children  throw  some  light  thereon.  In  children  the  ideas  are 
simj)le,  few  and  disconnected.  The  ideas  are  therefore  incoherent 
by  reason  of  an  absence  of  organic  associaoion  between  the 
residua.  The  morbid  phenomena  are  not  systematised  as  in  the 
adult,  and  the  result  is  delirium  rather  than  mania  (Maudsley). 
The  morbid  idea  in  the  child's  mind,  having  little  range  of  action 
on  other  ideas,  acts  downwards  on  the  sensory  ganglia,  causing 
hallucinations,  or  on  the  movements,  giving  rise  to  morbid 
imj^ulses  (Maudsley).  These  impulses  constitute  impulsive 
insanity,  called  by  Maudsley,  monomania,  and  by  Morselli, 
paranoia  rudimentaria  impidsiva.  Under  the  head  of  monomania 
also,  Maudsley  places  the  epidemics  of  morbid  ideas,  which  have 
from  time  to  time,  in  the  history  of  the  world,  aff"ected  children. 


238       ,  PATHOLOGY. 

(Choreic  Insanity  is  mentioned  above,  and  described  in 
Chap.  III). 

The  ruling  instinct  in  a  child  of  3  or  4  is  self-gratification, 
involved  in  which  is  a  tendency  to  destroy  what  it  clislikes.  Its 
insanity  is  manifested  by  perverse  and  unreasoning  appropriation 
of  whatever  it  sees,  and  by  extreme  destructiveness ;  it  suffers 
from  the  instinctive  variety  (Maudsley)  of  affective  or  moral 
insanity.  (For  description  of  Moral  Insanity  and  Moral  Imbe- 
cility, see  Chap.  III.)  Maudsley  describes  a  case  of  moral 
insanity  in  a  boy  in  which  the  cutaneous  sensibility  was  com- 
pletely lost  during  attacks  of  irresistible  violence,  returning  in 
the  docile  intervals.  This  is  interesting  in  the  light  of  the 
present  knowledge  of  the  motor  area.  He  also  describes  another 
case  in  which  the  cutaneous  sensibility  was  deficient.  More  or 
less  cutaneous  anaesthesia  is  frequently  observed  in  persons 
suffering  from  morbid  or  immoral  impulses  or  propensities 
symptomatic  of  cerebral  exhaustion.  Lombroso  and  others  find 
distinctive  bodily  as  well  as  cerebral  characteristics  in  criminals, 
adult  or  juvenile.  Maudsley  also  describes  a  form  in  children 
called  cataleptoid  insanity.  There  is  mystical  contemplation  with 
insensibility  sometimes,  or  vague  answers,  or  incoherent  raving, 
or  sudden  wild  shrieking.  There  are  intermediate  forms  between 
this  and  chorea,  and  the  attacks  sometimes  alternate  with  true 
epileptic  seizures.  The  same  author  says  ej^ileptic  insanity  in 
children  resembles  the  same  disease  in  adults  (see  Chap.  III.). 

Melancholia  may  occur  in  childhood.  The  child  is  constantly 
wailing  and  whining;  every  impression  causes  a  painful  feeling. 
There  may  also  be  delusions  and  suicidal  tendency. 

Mania  (delirium  of  young  children)  may  occur  in  childhood  in 
connection  with  convulsions  (the  most  usual  pathogenetic  factor), 
blows  on  the  head,  intestinal  worms,  and  onanism.  There  may 
be  extreme  violence  and  even  homicidal  tendencies.  "  The 
question  of  hereditary  taint  is  in  reality  the  important  question 
in  an  examination  of  the  insanity  of  early  life  "  ( Maudsley). 

With  regard  to  the  cortical  cells  of  the  brain  their  sparseness, 
or  extensive  degeneration,  gives  rise  to  mental  weakness  as  shown 
by  diminished  or  originally  slight  power  of  perception,  apprehen- 
sion and  attention,  defective  memory,  weak  judgment,  absence  or 
weakness  of  volition  or  of  inhibitory  power.  These  conditions, 
pathological  and  clinical,  are  found  in  idiocy,  terminal  dementia, 
general  paralysis,  chronic  alcoholic  insanity,  senile  dementia, 
chronic  epileptic  insanity.  In  these  forms  there  are  frequently 
motor  and  sensory  disturbances.  The  pathological  conditions  in 
the  acquired  forms  at  least  are  led  up  to  by  a  series  of  changes 
{inde  supra)    commencing  apparently  with  vascular  disturbances, 


PATHOLOGY.  239 

though,  according  to  Maudsley,  these  are  themselves  originated 
by  alterations  (inai^preciable,  macroscopically  or  microscoj)ically 
at  present)  in  the  contents  of  the  cerebral  cortical  cells.  Meynert 
("Lectures"  at  Gen.  Hosp.,  Vienna,  Session  1876-77)  believes  that 
although  in  a  general  way  cerebral  hypersemia  may  be  looked 
upon  as  the  basis  of  mania  and  cerel)ral  anaemia  of  melancholia, 
yet  cerebral  hypereemia  is  not  equivalent  to  maniacal  excitement, 
nor  cerebral  anaemia  to  melancholic  depression.  There  must  be 
an  alteration  in  the  state  of  the  nervous  elements. 

Some  authorities  hold  the  view  that  general  epilepsy  is  cortical, 
but  Mendel  thinks  it  is  primarily  bulbar.  According  to  Hughlings- 
Jackson  unilateral  epilepsy  is  caused  by  an  irritative  lesion  in  or 
near  the  motor  cortex.  The  hyperemia  arising  from  such  a 
lesion  induces  over-nutrition  of  the  large  pyramidal  cells  resulting 
in  periodical  explosions  of  nervous  energy.  B.  Lewis  thinks  the 
small  pyramids  (sensory  cells)  of  the  cortex  inhibit  the  large 
motor  cells  of  the  third  layer.  He  found  the  former  degenerated 
in  general  epilepsy.  Meynert  attaches  much  importance  to  the 
atrophy  of  the  pyramids  of  the  stratum  convolutum.  The  cell 
degenerations  described  by  these  two  authors  may  be  secondary. 
Brown-Sequard  found  that  lesions  of  the  right  hemisphere  were 
much  more  frequently  accomjDanied  by  convulsions  and  conjugated 
deviation  than  those  of  the  left.  It  is  of  some  interest  in  this  con- 
nection that  hysterical  symptoms  (tremor,  anaesthesia,  paralysis)  are 
exceedingly  frequent  on  the  left  side  of  the  body  as  compared  with 
the  right  (Brown-Sequard).  Transitory  mania  resembles  epileptic 
insanity  in  some  respects,  but  occurs  only  once  in  a  lifetime. 

Many  cases  of  mental  disease  develop  out  of  physiological 
states.  In  some  cases  hallucinations  and  illusions  (hence  called 
hypnagoguic,  Morselli)  develop  out  of  drecxms,  or  arise  during 
the  half  waking,  half  sleeping  state,  and  constitute  in  suitable 
soil,  the  germs  of  many  delusions.  Sadness  of  disposition, 
extreme  scrupulousness,  religious  zeal,  suspicion,  pride,  ambition, 
etc.,  may,  under  the  influence  of  the  environment  in  a  structurally 
predisposed  individual,  easily  overstep  the  physiological  limits. 

Meynert's  theory  of  the  production  of  hallucinations  is  that 
there  is  irritation  of  the  ganglia,  the  impressions  so  produced 
being  received  by  the  cells  of  a  cerebral  cortex,  of  which  the 
activity  is  diminished.  Luys  ("Le  Cerveau")  believes  they  are 
caused  by  a  diseased  condition  of  the  optic  thalami.  Tamburini's 
view  is  that  they  are  caused  by  derangement  or  irritation  of  the 
cerebral  cortical  sensory  areas  (Ireland).  The  last  theory  is 
most  in  accord  with  what  is  at  present  known  of  the  anatomy, 
physiology,  and  pathology  of  the  brain. 

Hallucinations  are  certainly  caused  in  some  cases  by  irritation 


240  PATHOLOGY. 

of  the  ganglia,  or  of  some  part  of  the  sensory  tract  Ijetween  the 
sense  organ  and  the  cerebral  cortex.  J.  L.  Koch  ("AUg.  Zeit.") 
would  call  such  hallucinations  illusions,  but  this  -would  only 
create  confusion.  According  to  Despine  ("  L'Encephale ") 
whether  hallucinations  originate  in  the  cortex  cerebri  or  in  the 
centripetal  tracts,  they  take  a  centrifugal  course  from  the  former 
to  the  organs  of  sense.  This  Avould  explain  the  fact  that  prisms 
cause  diplopia  with  reference  to  hallucinations  just  as  if  they 
were  real  objects.  Arterial  spasm  sometimes  causes  hallucina- 
tions (Meynert).  In  addition  to  the  methods  already  mentioned, 
hallucinations  may  also  arise  out  of  the  delusions.  The  foi'm 
taken  by  hallucinations  is  influenced  to  a  great  extent  by  the 
disposition  or  humour  of  the  patient. 

The  suicidal  tendency  of  melancholia  may  originate  from  the 
patient  having  sustained  some  shock  to  his  secondary  individuality 
(olijects  connected  with  ambition,  love  of  wealth,  family  affection, 
patriotism,  etc.).  All  men  try  to  escape  from  the  pain  which  is 
the  most  intense  ;  the  secondary  individuality  has  Ijecome  more 
valuable  to  the  individual  than  the  primary  ;  he  sacrifices  the 
latter  to  escape  from  the  anguish  caused  by  the  injury  to  the 
former  (Meynert). 

Angry  excitement  arises  from  hypertesthesia  of  the  nervous 
elements,  as  shown  by  the  increased  acuteness  of  the  senses 
(Meynert).  Meynert  thinks  it  probable  that  exaltation  arises 
from  an  excess  of  oxygen  in  the  encephalon. 

Certain  sjmiptoms  are  seldom  absent  in  insanit}",  viz.  : — 
(1,)  In  acquired  insanity  in  the  early  stages:  («,)  Insomnia  (not 
due  to  pain),  of  which  something  has  already  been  said  ;  (b,) 
Alteration  in  disposition  and  conduct  (perversion,  or,  less 
commonly,  exaggeration)  due  to  over-action  of  part  or  parts  of 
the  brain;  ('",)  Prolonged  sense  reaction-time,  the  result  of 
defective  nutrition  of  the  fibres  and  cells,  or  caused  by  the 
pressure  exerted  on  the  fibres  b}^  the  distended  blood-vessels ; 
(c/,)  Physiognomical  alterations,  arising  from  emotions,  circulation, 
iiniervation,  etc.  As  showing  the  intimate  relation  Avhich  exists 
between  almost  all  the  emotions  and  their  outward  manifestations, 
it  is  an  interesting  fact  that  even  the  simulation  of  an  emotion 
tends  to  arouse  that  emotion  in  the  mind  (Darwin,  "  Expression 
of  the  Emotions  in  Man  and  Animals  "). 

(2,)  In  chronic  and  congenital  insanity  :  («,)  Mental  or  moral 
weakness,  owing  to  degeneration  or  congenital  defect  of  brain 
structure  ;  {b,)  Muscular  weakness  due  to  the  same  cause  ;  (c,) 
Prolonged  sense  reaction-time  ;  (d,)  Physiognomical  deterioration 
or  alteration  in  consequence  of  vaso-motor  defects  or  irregularities  ; 
mal-innervation  or  irregular  innervation   of    the  facial  muscles 


PATHOLOGY.  241 

gives  rise  to  incompatible  expressions  ;  the  long  continuance  of 
some  facial  expression  corresponding  to  disagreeable  emotions  ; 
changes  in  the  skin  itself.  The  facial  deterioration  is  more 
marked  in  females. 

I  mention  the  following  cases  as  constituting  an  example  of 
the  complex  nature  of  the  pathogenesis  of  many,  if  not  all,  of  the 
acquired  primary  insanities  : — Eleven  patients,  recently  treated  by 
me  in  private  practice,  were  suflFering  from  climacteric  neurosis. 
They  were  not  insane,  but  on  the  borderland — such  cases  as  one 
never  meets  in  asylums.  They  were  all  females,  married,  and 
aged  between  43  and  50.  Hereditary  taint  was  ascertained  in 
two  or  three,  and  it  probably  existed  in  more.  All  suffered 
more  or  less  from  menstrual  irregularities.  Five  of  them  had 
had  no  children  after  the  age  of  30,  two  none  after  the  age  of  40, 
and  four  were  childless.  There  would  thus  seem  to  be  some 
causative  relationship  between  sterility  and  climacteric  neu- 
I'osis.  Several  had  been  in  the  habit  of  drinking  strong 
tea  three  or  four  times  a  clay.  Most  of  them  evinced  shyness, 
avoiding  alike  society,  fresh  air,  and  sunshine ;  true  this 
was  a  symptom,  but  one  likely  to  prove  very  damaging  to  the 
mental  ecjuilibrium,  and  to  become  an  etiological  factor  in  the 
production  of  real  insanity,  if  not  resisted.  AH  suffered  from 
more  or  less  severe  dyspeptic  symptoms.  One  was  so  nervous 
and  apprehensive  that  she  ran  out  of  the  house  the  moment  she 
saw  me  take  up  a  stethoscope.  In  three  or  four  there  was  a 
craving  for  alcoholic  stimulants  :  this  was  acknowledged  and 
deplored  by  two.  It  is  an  alarming  symptom,  as  the  alcoholic 
habit  can  be  very  readily  established  at  this  period  of  life. 
Alcoholic  indulgence,  still  further,  hastens  the  patient's  progress 
to  insanity,  and  must  be  prevented  at  all  hazards.  Several 
suffered  from  insomnia,  which  is  easily  remedied  at  this  stage,  but 
greatly  aggravates  matters  if  neglected.  The  therapeutical 
indications  were  manifestly  to  remove  the  removable  causes  and 
symptoms,  and  so  assist  the  patients  to  pass  through  the  critical 
physiological  period.  Six  of  the  cases  have  recovered,  two  have 
gone  to  distant  towns,  and  three  have  been  already  relieved  and 
Avill  probably  recover,  attaining  the  post-climacteric  age  without 
the  necessity  of  any  but  home  treatment. 


16 


242  THERAPEUTICS   AND   HYGIENE. 


CHAPTER    VIII. 

THERAPEUTICS    AND   HYGIENE. 

Prophylaxis. 

This  should  be  commenced  in  infancy,  where  there  is  hereditary- 
predisposition  to  mental  disease.  These  neuropathic  children 
ought  to  be  brought  up  by  a  healthy  wet  nurse.  Rooms,  clothing, 
and  baths  must  not  be  too  warm.  Especial  care  should  be  taken 
dui'ing  the  first  dentition  to  avoid  cerebral  hyperaemia  and  con- 
vulsions. The  children  ought  to  be  much  in  the  fresh  air,  and 
have  a  nutritious  unstimulating  diet,  free  from  tea,  coffee,  or 
spirits.  They  should  be  early  taught  obedience,  the  character 
strengthened,  passionate  ebullitions  and  sentimentality  dis- 
couraged, and  quietude  and  self-control  inculcated.  Where  the 
intellect  is  precocious  it  should  be  restrained,  where  backward, 
treated  with  patience  ;  there  must  be  no  forcing.  If  the  parents 
are  perverse,  hypochondriacal,  or  hysterical,  the  children  ought, 
if  possible,  to  be  removed  from  them  and  educated  in  the  private 
house  of  a  medical  man,  teacher,  or  clergyman  in  the  country. 
Everything  likely  to  promote  sexual  development  should  l)e 
avoicled.  About  the  time  of  pubert}"  much  care  is  required,  and  any 
disease  (chlorosis,  etc.)  that  may  arise  must  be  energetically  treated. 
Novel  reading,  as  well  as  religioixs  fanaticism,  is  to  be  avoided. 
Males  ought  to  marry  early,  but  females  should  be  previously 
fully-developed  in  order  to  be  able  to  combat  the  clangers  of 
gestation  and  the  puerperium.  Suckling  must  not  be  allowed,  or 
only  for  three  months  at  most.  During  the  puerperium  the 
treatment  should  be  strengthening.  The  occupation  of  these 
persons  should  not  be  exciting  ;  they  ought  to  live  a  quiet, 
regular  life,  attend  to  the  functions  of  the  digestive  organs,  and 
avoid  the  abuse  of  pleasures  of  anv  kind  (Krafft-Ebing,  "  Lehrb. 
der  Psych.,"  pp.  281-283). 

A  well-regulated  system  of  gymnastic  exercises  will  be  found 
to  diminish  or  even  to  check  the  morbid  propensities  from  which 
children  of  neurotic  diathesis  suffer.  In  youth  riding,  driving, 
walking,  cycling,  rowing,  and  SAvimming  are  useful. 


THERAPEUTICS  AND   HYGIENE.  24-: 


Eemedial  Treatment. 


I. — THE    immediate   RELIEF   OF   URGENT   SYMPTOMS. 
II. — ULTI1VL4TE   CARE   AND   TREATMENT. 

l.-^Relief  of  symptoms. 

A. — Insomnia.  An  actual  attack .  of  insanity  may  often  be 
warded  off  by  relieving  the  premonitory  insomnia.  In  some 
forms  of  insanity  (acute  delirium,  acute  mania),  insomnia  may 
assist  in  the  induction  of  fatal  exhaustion.  Bucknill  and  Tuke 
consider  that  as  a  general  rule  it  should  not  be  allowed  to  con- 
tinue more  than  three  consecutive  nights  without  the  administra- 
tion of  a  hypnotic. 

Chloral  Hydrate. — Clouston  recommends  10  to  25  gi-ains  with 
from  3ss  to  5J  of  pot.  bromid.  at  night  in  states  of  mental 
exaltation.  Spitzka  gives  equal  parts  of  chloral  and  bromide 
of  jDotassium  in  mania.  I  have  generally  found  from  20  to  30  grains 
of  chloral  act  well.  In  some  cases  a  dose  of  gr.  xv  will  do,  and  if  it 
fails,  it  can  be  repeated  in  three-Cjuarters  of  an  hour.  In  apyretic 
delirium  tremens  an  otherwise  healthy  man  may  have  40  grains 
at  bedtime,  or  30  grains  may  be  given  and  repeated  in  an  hour 
if  required  ;  these  doses  have  induced  the  critical  sleep  in  eight 
cases  under  my  ctire  in  private  practice.  Contraindicated  in  acute 
delirium,  states  of  mental  depression,  visceral  disease,  especially 
cardiac  and  pulmonary,  and  febrile  delirium  tremens. 

Occasionally  it  causes  excitement  instead  of  sleep.  Occasion- 
ally it  does  not  act  hypnotically  till  the  night  following  that  on 
which  it  is  administered. 

The  patient  may  be  induced  to  take  it  in  a  little  beer  or  spirit 
and  water.  When  patients,  suffering  from  neurasthenia  or  mild 
melancholia,  wake  very  early  and  cannot  go  to  sleep  again,  give  40 
grains  two  or  three  times  a  week  when  they  aAvake,  until  the  habit 
is  broken  (Stretch  Dowse,  "Brain  and  Nerve  Exhaustion,"  p.  56). 

Paraldehyde. — This  may  be  given  when  chloral  is  contraindi- 
cated. Dose  5ss  to  5ij.  Medium  dose  5j  given  at  bedtime  with 
a  little  syrup  of  orange,  tragacanth  mucilage  and  water. 

Sidplional. — When  chloral  is  contraindicated.  Dose,  as  a  hyp- 
notic, gr.  XV  to  5ss,  or  even  5j  given  early  in  the  evening  in  a  cupful 
of  hot  fluid,  preferably  milk.  Having  no  smell  and  only  a  very 
slightly  bitter  taste,  it  may  be  given  with  the  food  when  the  patient 
refuses  to  take  anything  he  knows  to  be  medicated.  During  the 
past  two  years  I  have  given,  in  private  practice,  sulphonal  as  a 
hypnotic  in  more  than  forty  cases  of  insomnia  from  various 
causes,    influenza,    alcoholism,    climacteric    neurosis,    puerperal 


244  THERAPEUTICS  AND  HYGIENE. 

insanity,  acute  delirium,  adolescent  insanity,  hysteria,  grief,  etc., 
and  have  found  it  act  well  in  all  but  a  few  cases,  the  only  ill-effect 
being  vomiting  in  one  case.  In  a  case  of  alcoholism  in  a  female 
it  failed  to  induce  sleep,  and  here  a  dose  of  chloral  (gr.  xl)  had 
the  desired  effect.  Sulphonal  Avas  given  in  doses  of  gr.  xv  to  gr. 
XXX  for  females,  and  gr.  xx  to  gr.  xl,  or  occasionally  3j  for  males. 
The  addition  of  hyd.  c.  cret.  (gr.  i.,  ii.  or  iii.)  seemed  to  increase 
the  certainty  of  its  action. 

Krafft-Ebing  speaks  well  of  Hypnone  in  doses  of  15  to  20, 
or  even  30  drops.  It  procures  several  hours'  deejj  refreshing 
sleep  without  disagreeable  after  effects.  Conolly  Norman  ("Jour. 
Ment.  Sci.,"  Jan.,  1887)  recommends  its  subcutaneous  use. 
Surzycki  found  it  act  very  unsatisfactorily  in  closes  of  Til  1^ 
to  ni7|  ("Prov.  Med.  Jour.,"  July,  1891). 

Henhane. —  Recommended  by  Clouston  in  doses  of  5j  to  3SS 
of  the  tincture  as  a  temporary  expedient  in  the  very  agitated 
cases  of  melancholia. 

Cannabis  Indica. — Clouston  has  found  a  mixture  of  the 
tincture  (from  x  min.),  and  bromide  of  potassium  (from  xx  grs.) 
do  more  good  than  any  other  narcotic,  and  act  less  injuriously  on 
the  appetite  in  cases  of  melancholia. 

H'l/oscyamiae. — Hypodermically  ;  when  the  patient  will  not  or 
cannot  be  got  to  take  medicine.  Acts  in  half-an-hoiu'  to  an  hour, 
and  sleep  lasts  from  two  to  eight  hours,  according  to  the  dose. 
Acts  more  certainly  and  quickly,  and  in  smaller  doses  than  when 
given  by  the  mouth.  Dose  (of  Merck's  crystalline)  as  a 
hypnotic  for  strong  .  adult,  gr.  J^  (hypodermically),  increased 
rapidly  or  slowly,  according  to  the  effect  (Brown,  "  Braithwaite's 
Retrospect,"  vol.  Ixxxvii).  I  usually  commenced  with  gr.  ttV  (hypo- 
dermically) for  a  man,  and  gr.  ^q  for  a  woman,  and  in  men  have 
increased  the  dose  to  gr.  5  without  ill  effects.  It  should  not 
be  given  to  weak  or  exhausted  patients. 

Hyoscine  Hydrohr ornate. — Fischer  ("Braithwaite's  Retrospect") 
gave  hypodermically  120  to  eV  in  several  cases  with  success. 
Fischer  also  used  hyoscinum  hydrochloricum  in  doses  of  1-3-0  to 
gV,  and  even  jV  of  a  grain  satisfactorily,  both  as  a  calmative  and 
hypnotic  ("Medical  Annual,"  1889). 

Da  Costa  ("Jour.  Nerv.  and  Ment.  Dis.")  says  hyoscine  is 
of  great  value  for  occasional  use,  but  must  not  be  given  con- 
tinuously for  a  long  time.  It  produces  disagreeable  symptoms, 
and  if  long  given,  hastens  dementia.  It  may  be  given  in  cases  of 
epileptic  mania,  transitory  mania,  maniacal  furor,  excitement  of 
general  paralysis,  ordinary  mania  with  marked  destructive 
tendencies,  melancholic  frenzy,  uncontrollable  impulses,  as  a 
calmative. 


THERAPEUTICS   AND   HYGIENE.  245 

Piscidia  Erythrina  (Jamaica  Dogwood)  and  the  Bromides 
diminish  sensory  hypersesthesia,  and  by  removing  somatic  and 
psychical  irritation  often  procure  sleep  indirectly. 

Metliylal. — In  alcoholic  cases  Krafft-Ebing  gives  TH.  1|,  hypo- 
dermically,  in  a  syringeful  of  distilled  water  from  one  to  three 
times  in  the  twenty -four  hours.  It  takes  effect  in  an  hour  or  two. 
Sleep  is  deep  and  refreshing  without  ill  after  effects.  (See  treat- 
ment of  "  Delirium  Tremens.") 

Amylene  Hydrate. — Found  by  Scharschraidt,  Girtler,  Von 
Mering,  and  others,  to  act  satisfactorily.  Use  not  contraindicated 
in  cardiac  or  digestive  affections.  Dose,  TT|_xx  to  xlv  or  1,  or  even 
xc,  given  with  Avine,  peppermint,  or  extract  of  liquorice  ("  Med. 
Annual ").  Surzycki  prefers  it  to  sulphonal  in  cases  of  insomnia 
with  general  excitement  or  delirium.  It  never  causes  any 
unpleasant  effects  even  in  large  doses  (4  to  8  grammes).  Urethaii 
is  much  inferior  to  it,  and  to  sulphonal,  according  to  Surzycki 
("Prov.  Med.  Jour.,"  July,  1891). 

Chloralamide. — Gordon  and  others  have  found  it  very  satis- 
factory in  the  treatment  of  the  insomnia  of  old  age,  hysteria,  and 
pulmonary  diseases.  It  is  most  useful  where  there  is  little  or  no 
pain.  Dose  30  to  45  grains.  ("Brit.  Med.  Jour."  and  "Jour. 
Ment.  Sci.'O- 

Auxiliary  measures  (which  may  also  be  tried  first,  especially  in 
mild  cases) ;  keep  head  high  and  cool  and  feet  warm  ;  wet  packing  ; 
warm  foot  baths  ;  warm  drinks  at  bed-time  ;  hot  milk  ;  warm 
beef  tea ;  warm  beef  tea  and  spirit ;  Avarm  spirit  and  water  ; 
stout ;  raw  onions ;  dark  and  quiet  room ;  galvanic  current 
through  head ;  head  to  north  ;  in  states  of  inanition,  head  low. 
(See  "Pulse,"  chap.  II.  of  this  work.)     Change  of  scene. 

In  mild  cases  of  "  agrypnia,"  Krafft-Ebing  recommends  quin. 
valer.,  in  doses  of  gr.  jss.  Lactic  acid,  in  large  doses,  acts  as 
a  mild  hypnotic.  In  cases  of  mental  overwork  and  worry, 
strychnine,  in  small  repeated  doses,  will  sometimes  induce  sleep. 

Hypnotism,  especially  the  Nancy  method  (by  "suggestion"), 
has  been  found  to  act  well  in  some  hysterical,  toxic,  neurasthenic, 
convulsive  and  paralytic  cases. 

B.^Motor  Excitement,  Noisiness,  Destructiveness, 

Spitzka  considers  Conium  "the  best,  most  reliable,  and  safest 
drug  "  to  control  motor  excitement  in  mania.  He  uses  Squibb's 
fluid  extract  and  gives  20  minims  as  an  initial  dose,  and  then 
from  10  to  15  minims  every  hour  or  half -hour  until  the  excite- 
ment is  subdued.  He  says  larger  doses  may  be  given  to  patients 
whose  tolerance  has  been  tested. 

In  the  restlessness  and  excitement  of  melancholia  Clouston  has 
found  a  mixture  of  tinct.  cannab.  indie,   (from  x  min.)  and  pot. 


246  THERAPEUTICS   AND   HYGIENE. 

l:)roniide  (from  xx  grs.)  do  the  most  good,  whilst  it  at  the  same- 
time  does  the  least  harm  to  the  appetite  for  food. 

In  strong,  violent,  maniacal  patients,  small  doses  (yroth  to  :^oth 
of  a  grain)  of  Merck's  crystalline  hyoscyamine  may  be  given  hypo- 
dermically  and  repeated  several  times  a  day  according  to  the  effect. 
This  will  be  also  found  useful  when  removing  to  an  asjdum, 
or  elsewhere,  a  violent  patient  Avho  refuses  to  take  medicine. 

Krafft-Ebing  (pp.  294-297)  considers  Opium,  administered 
subcutaneously  or  per  rectum,  one  of  the  most  important 
sedatives:  (1,)  It  diminishes  psychical  hypersesthesia  and  prae- 
cordial  anxiet}''.  In  this  way  it  very  often  acts  hypnotically  ; 
(2,)  It  stimulates  the  vaso-motor  nerves,  thereby  contracting  the 
vessels  ;  (3,)  It  has  trophic  actions  on  the  central  nervous  system 
and  promotes  nutrition.  Blandford,  Schiile,  Ziehen,  Tellegen, 
strongly  advocate  the  use  of  opium  in  melancholia.  It  induces 
sleep  and  relieves  mental  anguish.  It  acts  best  in  anaemic  con- 
ditions and  in  elderly  persons. 

The  vaso-motor  and  sedative  actions  of  Morphia  are  more 
powerful  than  those  of  opium,  but  the  trophic  actions  are  absent. 
Morphia  is  best  given  hypodermically  in  the  psychoses.  It 
is  indicated  in:  (1,)  Melancholy  conditions  with  neuralgic  or 
vaso-paretic  symptoms  ;  (2,)  Paranoia  AAath  physical  persecutory 
delusions,  auditory  hallucinations,  hallucinatory  paranoia  ;  (3,) 
The  irritable  excitement  of  declining  mania,  and  the  angry, 
passionate  outbursts  of  imbeciles;  (4,)  The  episodical  excitement 
of  general  paralytics ;  (5,)  The  episodical  excitement  of 
chronic  forms ;  (6,)  Periodical  mania  and  circular  excitement 
A\'ith  vaso-motor  prodromata  (small  tense  pulsus  celer} ;  here  it 
should  be  giA'^en  in  large  doses. 

Codeia  is  not  constipating  and  stupefying  like  opium,  and  does 
not  induce  a  crave  like  morphia.  Its  strength  a^.  a  narcotic  is 
about  one-third  of  that  of  morphia  ;  the  muriate  may  be  given 
internally,  and  the  phosphate  subcutaneously.  It  was  tried 
successfully  eighteen  years-  ago  in  excited  cases  in  Norfolk  County 
Asylum.  Tinct.  of  Veratnim  Viride  was  used  about  the  same  time 
in  the  same  asylum  in  the  episodical  excitement  of  chronic  mania, 
and  was  found  to  act  beneficiall3^  Since  then  it  has  been  recom- 
mended  by  Mickle  in  general  paralysis.  In  1877,  Meynert 
recommended  the  use  of  veratrin  in  the  episodical  excitement  of 
general  paralysis. 

As  auxiliaries,  abundance  of  fluid  nourishment,  milk,  beef  tea, 
raw  eggs ;  out-door  exercise,  where  not  contraindicated  by 
pyrexia  or  physical  Aveakness  or  the  immediate  surroundings  of 
the  patient.  -  Where  there  is  constipation  or  diarrhoea,  caused  by 
constijDation,  sj  ol.  ricini  or  gr.  a'.  calomel  may  be  given,  or  from 


THERAPEUTICS   AND   HYGIENE.  247 

gr.  I"  to  gr.  2  aloin  may  be  administered  hypodermically,  at  first, 
the  action  of  the  bowels  being  afterwards  maintained  by  diet, 
exercise,  and,  if  necessary,  cascara,  or  occasionally  tamar  indien. 

Willoughby  ("Lancet,"  1889,  vol.  i.,  p.  1030)  reports  the  good 
effects  of  Pilocarpine  in  a  case  of  threatening  mania ;  and  Lyon 
("Jour.  Nerv.  and  Ment.  Dis.,"  N.Y.,  1889,  vol.  xvi.,  p.  254)  in 
hystero-epilepsy  and  maniacal- excitement.  Li  1888  I  injected 
gr.  50  pilocarpine  nitrate  subcutaneously  in  a  man  of  insane  diathe- 
sis and  heredity,  suffering  at  the  time  from  maniacal  motor  excite- 
ment. He  went  to  sleep  half-an-hour  afterwards,  and  slept  all 
night  and  well  on  into  the  next  day.  He  made  a  good  recovery, 
and  was  at  work  in  a  few  days.  He  thoiight  the  substance 
injected  was  morphia.  He  was  quite  conscious  during  the  excite- 
ment, which  somewhat  resembled  some  of  the  stages  of  Charcot's 
hystero-epilepsy.  About  the  end  of  1889  I  injected  gr.  :3V  into 
the  arm  of  a  young  man  suffering  from  confusional  excitement 
of  a  somewhat  hysterical  kind,  with  motor  restlessness,  caused 
by  fright  at  night.  He  was  at  business  next  day.  However,  in 
his  case  I  gave  gr.  xxx  sulphonal  about  half-an-hour  after  the 
hypodermic  injection. 

Weatherly  ("Jour.  Ment.  Sci.,"  July,  1891)  gives  the  dose  of 
hyoscine  as  gr.  gjo-rmj;  increased  very  cautiously  to  sV-  He  says 
it  should  be  given  in  repeated  small  doses,  and  its  effects  carefully 
Avatched.  He  considers  it  to  be  safer  than  hyoscyamine. 
According  to  him  its  uses  are  to  act  as  a  mental  alterative  in 
troublesome  cases,  and  as  a  calmative  in  tremor,  and  in  motor 
excitement  when  not  hysterical.  Pilocarpine  is  an  antidote. 
(See  "  Pilocarpine.") 

C — The  Refusal  of  Food  and  inability  of  the  patient  to  feed  himself- 

The  refusal  of  food  may  arise  from  :  (a,)  Mere  anorexia  (loss 
of  appetite);  (&,)  Subjective  depressive  ideas,  as  in  melancholia, 
the  patient  believing  himself  unfit  to  live,  or  labouring  under  the 
delusion  that  his  bowels  are  stopped  up,  etc.;  (c,)  From  delusions 
that  he  has  been  commanded  by  the  Supreme  Being  not  to  take 
food  or  drink,  or  that  people  are  attempting  to  poison  him;  (d,) 
From  mere  ill-temper,  whim,  or  caprice. 

In  cases  of  delusional  insanity  (c,)  there  may  be  gastric  dis- 
order indicating  gastric  rest;  other  symptoms  will  have  already 
given  rise  to  preparations  for  the  patient's-  permanent  treatment ; 
eating  is  often  resumed  voluntarily,  and  these  patients  are 
generally  physically  stronger  than  the  melancholic  ones  (h). 
The  latter,  as  well  as  those  suft'ering  from  anergic  stupor,  and 
therefore  unable  to  feed  themselves,  should  not  be  allowed  to  go 
more  than  two,  or  at  most  three  whole  days  AAathout  feeding. 


248  THERAPEUTICS   AND   HYGIENE. 

Class  (a,)  will  require  general  dietetic  and  therapeutical  measures. 
Class  {(l,)  will,  as  a  rule,  resume  eating  after  two  or  three  days' 
abstinence.  Maniacs  and  general  paralytics  generally  resume 
eating  voluntarily.  Some  recommend  that  melancholic  and 
stuporous  cases,  when  they  refuse  food,  should  be  fed  forthwith. 
The  anergic  patients  may  be  fed  by  simply  pouring  fluid  food  into 
the  back  of  the  mouth  by  means  of  a  wooden  spoon  or  a  metal 
feeding  cup.  The  melancholiacs,  especially  the  stuporous  ones, 
may  be  easily  fed  through  the  nose  by  means  of  an  ordinary  breast 
exhauster  (Saunders'  form),  about  three  inches  of  the  tube  being- 
left  attached  to  the  glass  reservoir  and  passed  along  the  floor  of  the 
nasal  cavity.  Fluid  food,  milk,  beef  tea,  switched  eggs,  etc*,  may 
be  poured  into  the  aperture  in  the  reservoir  intended  to  be 
applied  to  the  nipple  ;  the  reservoir  may  be  then  tilted  until 
a  tablespoonful  or  so  has  gone  down  the  pharynx,  and  this  can  be 
repeated  frequently,  allowing  the  patient  time  for  rest  and 
breathing  ;  half  a  pint  of  fluid  may  be  given  in  this  way  without 
alarming  the  friends  of  the  patient.  Feeding  may  be  done  in 
this  manner  three  or  four  times  a  day,  and  after  the  first  time 
the  quantity  may  be  increased  and  medicines,  port  wine,  brandy, 
etc.,  may  be  added.  As  a  rule,  this  method  of  feeding  can  only 
be  utilised  as  a  temporary  expedient,  as  the  patients,  or  many  of 
them,  learn  after  a  time  to  eject  the  fluid  by  the  mouth.  For 
more  eflfective,  though  much  more  formidable-looking  methods, 
viz.,  feeding  by  means  of  long  nasal  tube  and  stomach  tube, 
see  "  Ultimate  Care  and  Treatment."  Sometimes  a  patient  can 
be  induced  to  take  food  after  being  forcibly  fed  once,  either  by 
the  nose  or  mouth. 

Tellegen  and  others  advocate  the  use  of  opium  in  melancholic 
sitophobia.  Raspail  and  Voisin  recommend  washing  out  the 
stomach. 

D. — Suicide  or  Homicide. 

When  there  is  a  tendency  to  either  or  both  of  the  above  acts, 
the  patients  should  be  watched  night  and  day -by  trustworthy 
persons,  one  or  more  being  constantly  on  duty  according  to  the 
physical  strength  of  the  patient,  or  the  acuteness  of  the  case. 
Mechanical  restraint  is  not  advisable,  and  is  not  even  always 
effective,  Griesinger,  mentioning  a  case  where  the  patient  com- 
mitted suicide  whilst  in  a  straight  waistcoat.  If  the  patient  has 
actually  wounded  himself,  restraint  may  be  necessary  for  surgical 
reasons.  All  weapons,  razors,  knives,  fire-irons,  cords,  poisonous 
substances,  etc.,  should  be  kept  out  of  the  patient's  way;  and  he 
should  be  removed  as  far  as  possible  from  deep  Avater,  steep 
staircases,  railway  trains,  carriages,  etc. 


THERAPEUTICS   AND   HYGIENE.  249 

Tigges  and  Tellegen  believe  that  02mim  diminishes  the  suicidal 
inclination  in  melancholia.  The  latter  says  it  is  especially  useful 
and  reliable  in  private  practice.  He  advises  to  commence  with 
small  doses  of  mor]}Ua  subcutaneously  ("Jour.  Ment.  Sci., ' 
Oct.,  1891). 

11. — Ultimate  Care  and  Treatment. 

This  falls  into — 

A. — home  treatment. 

B. — PRIVATE   care     (single   PATIENTS). 
C. — ^ASYLUM  TREATMENT  AND    CARE. 

A. — Home  Treatment. 

This  term  is  applied  here  to  the  care  and  treatment,  with 
medical  aid,  of  semi-insane  or  uncertified  insane  persons  by  the 
near  relatives,  husband,  wife,  father,  mother.  It  is  not  intended 
to  imply,  as  will  be  seen  below,  that  the  patient  is  to  remain  in 
his  usual  abode. 

Mental  diseases  are  much  more  amenable  to  treatment  during 
their  prodromal  and  initial  stages  than  when  fully  developed, 
therefore,  in  the  chapter  on  Symptomatology,  the  symptoms  of 
these  stages  have  been  relatively  fully  described.  Change  of 
character,  irritability,  insomnia,  are  the  most  prominent  of  these 
early  symptoms.  As  in  all  other  diseases,  the  first  indication  in 
the  treatment  of  insanity,  incipient  or  developed,  is,  if  possible, 
to  remove  the  cause.  In  attempting  to  remove  the  immediate  cause 
of  the  symptoms  the  pathogenesis  must  be  taken  into  account. 

(1,)  It  may  be  necessary  to  diminish  the  encephalic  blood 
supply  :  {a,)  By  reducing  the  heart's  activity,  using  for  this  pur- 
pose digitalis,  aided  by  morphia,  hydrocyanic  acid,  cold  baths, 
cold  compresses  over  the  cardiac  region.  Acute  gastric  catarrh 
and  strong  sexual  excitement  contraindicate  the  prolonged  ad- 
ministration of  digitalis  ;  its  cumulative  action  should  not  be 
forgotten;  (&,)  By  dilating  the  peripheral  blood-vessels.  This  plan 
especially  recommends  itself  in  cases  of  prolonged  venous  hyper- 
semia  of  the  brain.  Warm  baths,  wet-packing,  wet-rubbing,  dry 
cupping,  purgatives  (saline  mineral  waters,  aloes,  rhubarb,  cascara, 
.  etc.),  fulfil  this  indication;  (c,)  By  causing  the  encephalic  blood- 
vessels to  contract.  To  this  end  apply  cold  compresses  or  the  ice-cap 
to  the  head,  or  cold  compresses  or  ice  along  the  course  of  the  great 
cervical  vessels.  General  mustard  baths,  mustard  foot-baths, 
large  mustard  poultices  to  skin  of  body,  act  in  a  reflex  manner  on 


250  THERAPEUTICS   AND   HYGIENE. 

the  vessels  of  the  pia,  and  cause  contraction  after  some  pre- 
liminary dilatation  (Heidenl^ain,  Schiiller,  Krafft-Ebing) ;  this 
method  is  useful  for  the  removal  of  venous  hypersemia.  Vascular 
constringents  are  nicotine,  hyoscyamus,  nux  vomica,  belladonna, 
quinine,  lead,  caffeine,  the  bromides,  small  doses  of  opium  and 
morphia,  and,  most  important  of  all,  ergot,  either  in  the  form  of 
liquid  extract  or  hypodermicall}^,  as  Bonj can's  or  Wernich's 
ergotin.  The  latter  drug  is  indicated  in  half  gramme  to  gramme 
doses  subcutaneously,  once  or  twice  daily  (Krafft-Ebing)  in 
excitement  due  to  congestion,  as  in  simple  mania,  acute  mania, 
paralytic  frenzy,  transitory  mania,  and  certain  stages  of  acute 
delirium. 

(2,)  It  may  be  advisable  to  augment  the  blood-supply  to  the 
brain :  (a,)  By  increasing  cardiac  activity.  In  conditions  of 
debility  and  exhaustion  connected  ^Yith.  the  functional  psychoses, 
spirits,  in  the  form  of  good  old  Avine,  beer,  and  punch,  are  given 
with  benefit,  as  they  improve  brain  nuti-ition,  encourage  sleep, 
and  diminish  or  retard  tissue  metamorphosis.  When  the  heart's 
action  is  very  weak,  prescribe  tea,  coffee,  brandy  and  egg  mixture, 
ether,  ethylic  alcohol.  In  collapse  and  threatened  syncope, 
subcutaneous  injections  of  sulphuric  ether  or  of  oil  of  camphor 
(1  to  10)  are  excellent;  (b,)  By  widening  the  bloodvessels. 
AVarm  poultices  or  warm  water  caps  to  the  head,  short  cold 
rubbings,  short  shower-baths,  short  hip-baths.  Ether,  chloroform, 
opium  and  morphia  in  large  doses,  and  above  all,  amyl  nitrite, 
dilate  the  vessels.  The  last  drug  is  also  a  cardiac  stimulant, 
dose  gtt.  4  to  6  by  inhalation  (Kraift-Ebing).  It  is  beneficial  in 
hemicrania,  angina  pectoris,  bronchial  asthma,  and  some  cases  of 
epilepsia  vaso-motoria.  Krafft-Ebing  thinks  it  useful  in  passive 
and  stuporous  melancholia,  with  extremely  defective  circulation, 
as  it  relaxes  the  initial  vascular  cramp  and  strengthens  the  heart, 
thus  causing  the  anaemic  brain  to  receive  more  blood  ;  {c,)  By 
facilitating  the  flow  of  blood  to  the  brain.  Best  in  bed  mth  head 
low  is  excellent  in  states  arising  from  inanition,  and  will  often 
procure  rest  more  cjuickly  than  narcotics  (Krafft-Ebing,  pp. 
290-293). 

Certain  causes  of  mental  disease,  e.g.,  mental  or  physical  over- 
exertion, alcoholic  or  sexual  excess,  certain  bodily  disorders 
(antemia,  neuralgia,  menstrual  disorders,  etc.),  and  privation,  are, 
or  should  be,  removable;  The  forms  of  insanity  capable  of  being 
cured  or  ameliorated  by  the  treatment  of  the  underlying  bodily 
disorders  or  functional  over-action,  are  insanity  from  abdominal 
disorders,  anaemic  insanity,  insanity  of  Bright's  disease,  conse- 
cutive insanity,  diabetic  insanity,  epileptic  insanity,  insanity  with 
exophthalmic   goitre,    hysterical    insanity,  lactational   insanity, 


THERAPEUTICS   AND   HYGIENE.  251 

raasturbational  insanity,  hypochondriacal  melancholia,  insanity  of 
myxcedema,  metastatic  insanity,  insanity  of  oxaluria  and  phospha- 
turia,  pellagrous  insanity,  phthisical  insanity,  podagrous  insanity, 
insanity  of  paralysis  agitans,  post-connubial  insanity,  primary 
mental  deterioration,  puerperal  insanity  (septicaemia,  infiamma- 
tion,  diminished  excretion  and  secretion,  loss  of  blood,  etc.), 
rheumatic  insanity,  anergic  stupor,  syphilitic  insanity,  toxic 
insanity,  traumatic  insanity,  uterine  or  amenorrhoeal  insanity. 
Apart  from  any  direct  causal  relationship  with  the  mental 
disease,  bodily  derangements,  general  or  local,  should  be  care- 
fully watched  for,  and  when  noticed,  promptly  treated. 
Other  causes,  such  as  disappointment  of  various  kinds,  adversity, 
fright,  shock,  etc.,  do  not  admit  of  this  indication  being  fulfilled, 
but  the  patient  may  be  removed  from  the  disagreeable  surround- 
ings more  or  less  intimately  associated  with  the  cause.  Change  of 
scene,  then,  is  the  second  indication  in  the  treatment  of  mental 
diseases,  and  a  very  important  one  it  is  in  almost  all  forms, 
frequently  (combined  with  the  first  indication)  preventing  an 
attack  passing  beyond  the  prodromal  or  initial  stage.  Even 
change  from  one  asylum  to  another  nearly  always  acts  beneficially 
and  is  often  curative ;  in  at  least  two  cases  of  many  months' 
duration  I  have  known  recovery  take  place  shortly  after  transfer. 
One  was  a  case  of  paranoia  (persecutional)  with  auditory  hallu- 
cinations, the  other  of  acute  mania  tending  towards  chronicity 
with  othaematoma. 

(3,)  The  patient  should  have,  and  if  possible,  in  a  fresh, 
bracing  atmosphere  by  the  seaside  or  on  the  hill-tops,  much 
out-door  exercise,  short  of  actual  fatigue.  In  cases  accompanied  by 
decided  pyrexia  or  great  physical  weakness,  this  would  be  of 
course  contraindicated. 

(4,)  The  f/ie;!  should  be  generous  and  consist  in  great  proportion 
of  nutritious  and  easily  assimilable  fluids,  such  as  milk,  switched 
eggs,  beef  tea,  soups,  etc.  From  two  to  six  quarts  of  milk  may 
be  given  in  the  twenty-four  hours,  constipation  being  avoided  by 
giving  fruit  in  the  morning,  and,  if  necessary,  drachm  doses  of  the 
ext.  cascar.  sagrad.  liq.  at  night. 

(5,)  The  treatment  erf  symptoms. — Insomnia  may  be  combated  by 
the  methods  already  mentioned  (pp.  243-24-5),  but  in  prodromal, 
incipient,  or  borderland  cases,  sulphonal  seems  very  useful,  as  it 
produces  a  soothing  and  quieting  effect  after  the  sleep  induced  by 
it  has  passed  off,  and  it  does  not  seem  to  act  so  deleteriously  as 
chloral  on  melancholiacs.  For  irritability,  restlessness,  erotic 
tendency,  epileptic  seizures,  give  pot.  bromid.  (from  xx  grs.) 
Avith  tinct.  cannab.  indica  (from  x  min.)  three  or  four  times 
a  day.    (See  "Treatment  of  Epilepsy,  Neurasthenia,"  etc.,  below). 


252  THERAPEUTICS   AND   HYGIENE, 

In  a  case  of  nem'astlienia  with  nocturnal  emissions,  I  gave  5j  of 
the  liquid  extract  of  salix  nigra  every  night  at  bedtime  ^vith  good 
effect.  In  three  cases  of  severe  dysmenorrhoea,  aggravated  by 
influenza,  one  i-drachm  dose  relieved,  and  three  or  four  doses 
at  intervals  of  four  hours  completely  arrested  the  excruciating  pain. 

Prsecordial  anxiety  may,  when  mild,  be  relieved  by  warm 
baths,  sinapisms  over  the  epigastrium,  ac.  hydrocyan.,  ext. 
belladon.,  and,  in  an  ill-nourished,  ansemic  patient,  rest  in  bed. 
In  severe  cases,  opiates  subcutaneously.  If  the  pulse  is  small  and 
not  frequent,  give  at  the  same  time  acetic  ether ;  if  it  is  frequent 
with  excited  caixliac  action,  tinct.  digital.  In  masturbatory 
cases,  especially  neurasthenic  ones,  chloral  hydrate  may  cut  the 
attacks  short  (KrafFt-Ebing,  o/).  cii.,  p.  .309). 

Meynert  says  baths  of  22°  C.  or  a  little  higher  are  excellent, 
soothing,  especially,  anxious  melancholiacs. 

In  auditory  hallucinations  from  hypersesthesia  of  the  acoustic 
centres,  Krafft-Ebing  recommends  a  trial  of  the  galvanic  current, 
and  says  he  has  obtained  favourable  results  from  the  administration 
of  morphia. 

For  depression,  nervous  exhaustion,  anorexia,  neuralgia,  give 
syrup  of  the  hypophosj)hites,  5j  three  times  a  day  in  a  wine- 
glassful  of  water  before  food.  Or  give  iron,  arsenic,  strychnine, 
phosphorus,  ol.  jecoris,  ergot,  opium,  zinc,  cocaine,  damiana,  or 
quinine,  singly  or  in  various  combinations,  according  to  the  case. 
Valerianate  of  zinc  in  the  form  of  pills,  beginning  with  one- 
grain  doses,  and  ^V  of  a  grain  of  the  jjhosphide  three  times  a  day 
after  food  may  be  given.  I  have  found  this  pill  with  a  mixture 
containing  arsenic,  very  beneficial  in  neurasthenia.  For  the 
relief  of  severe  neui"algia  or  headache,  4  grains  of  antifebrin  will 
be  found  useful,  and  this  dose  may  be  given  every  six  hours, 
or  antipyrin  in  8-grain  doses  every  hour  until  pain  is  relieved  or 
until  three  doses  have  been  given  (Kingsbiu^y).  In  a  case  of  mine 
of  severe  facial  neuralgia,  where  the  above  drugs  and  others  failed, 
phenacetin  in  20  grain  doses  twice  a  day  succeeded.  Where  there 
is  pain  arising  from  organic  disease  (tumour,  inflammation,  etc.) 
nothing  equals  morphia,  given  hypodermically.  For  other 
symptoms  see  ante    ("  Immediate  relief  of  urgent  symptoms  "). 

Elect ricitij.— Da  Watteville  ("Medical  Electricity,"  2nd  ed., 
p.  174)  says  it  may  be  used  as  a  remedial  agent  in  the  following 
diseases  and  conditions,  viz,,  chorea,  hysteria,  epilepsy,  neuras- 
thenia, insomnia,  cephalalgia  ;  cerebral  angemia  and  hypersemia  ; 
cerebral  hsemorrhage  and  ischsemic  softening  ;  cerebral  sclerosis 
or  degeneration.  The  galvanic  current  should  be  used  as  a  rule. 
It  should  be  very  weak  or  Aveak,  the  electrodes  being  applied  to 


THERAPEUTICS   AND   HYGIENE.  253 

the  head  or  head  and  neck  for  a  period  (to  be  cautiously  in- 
creased if  the  current  is  well  borne)  limited  at  first  to  one  to 
three  minutes.     Wiglesworth  has  found  it  useful  in  stupor. 

Tigges  ("Allg.  Zeit.")  treated  201  cases  of  insanity  with 
electricity ;  many  were  relieved,  and  24  (of  whom  seven  were 
stuporous)  of  the  melancholic  cases  cured. 

Massage — Savage  says  it  is  rarely,  if  ever,  useful  in  ordinary 
cases  of  insanity ;  its  chief  use  is  in  mental  depression  with 
physical  weakness,  loss  of  flesh,  and  deficient  action  of  the  gastro- 
intestinal tract.  Hack  Tuke  found  it  beneficial  in  one  case,  and 
curative  in  one  of  suicidal  religious  melancholia,  with  eroticism. 
It  is  much  used  by  Weir-Mitchell,  Stretch  Dowse  and  others  in 
neurasthenia",  though  its  application  in  this  complaint  is  considered 
useless  or  even  injurious  by  some  practitioners.  Jacoby  has 
found  it  valuable  in  neuralgia. 

Hypnotism. — Aug.  Voisin  has  by  means  of  hypnotic  suggestion 
cured  persons  suff'ering  from  the  following  conditions  and 
symptoms,  viz.,  hallucinations  and  delusions,  disturbances  of 
special  and  general  sensation,  suicidal  ideas,  acute  and  furious 
mania,  mania  and  agitation  during  catamenia,  dipsomania  and 
morphinomania,  onanism,  infantile  depravity,  amenorrhoea  in  the 
insane.  Relapses  were  not  more  than  a  tenth  of  the  cures 
("Jour.  Ment.  Sci.,"  1889).  Castelli  and  Sumbroso  cured  by 
this  means  a  case  of  hysterical  melancholia  ("Jour.  Nerv.  and 
Ment.  Dis.,"  1886).  Hack  Tuke  ("The  Influence  of  the  Mind 
upon  the  Body  ")  speaks  of  the  cure  of  hysterical  conditions  and 
even  of  organic  paralysis  by  Braidism.  By  the  latter  method  the 
patient  looks  at  a  bright  object  held  above  the  eyes  until  the 
hypnotic  state  is  induced  ;  this  is  the  method  used  by  Charcot 
and  his  school.  Passes,  loud  noises,  etc.,  will  also  bring  about  the 
condition.  In  the  Nancy  or  "suggestion"  method,  of  which 
Bernheim  is  the  chief  advocate,  the  patient  sits  in  a  chair  and  is 
told  by  the  physician  in  a  confident  tone  that  he  will  soon  go  to 
sleep,  that  his  sleep  will  be  natural,  that  he  is  feeling  drowsy,  etc. 
This  plan  was  known  to,  and  sometimes  practised  by.  Braid  and 
Faria.    Many  cases  of  neuralgia  have  been  cured  by  both  methods. 

Kraff"t-Ebing  believes  that  hypnotic  suggestion  is  a  valuable 
addition  to  the  therapeutics  of  functional  nervous  diseases. 
Wetterstrand  tried  it  in  718  cases  of  various  diseases  and  con- 
ditions. Of  these  only  19  were  not  susceptible.  It  acted 
satisfactorily  in  petit  mal  and  in  the  incipient  stages  of  the  less 
unfavourable  psychoses.  Brilliant  results  were  obtained  in 
anaemia  arising  from  leucorrhoea  and  dyspepsia,  and  Wetterstrand 
advises  beginners  to  commence  with  cases  of  this  kind.  He  and 
others  have  found  hypnotic  suggestion  unfailing  in  the  treatment 


254  THERAPEUTICS   AND   HYGIENE. 

of  incontinence  of  urine  in  children  ("Jour.  Ment.  Sci.").  E.  P. 
Smith  and  A.  T.  Myers  report  unfavourably  as  to  its  therapeutical 
effects  in  21  cases  of  insanity  ("Jour.  Ment.  Sci.,"  April,  1890). 

Where  an  attack  of  insanity  has  supervened  suddenly,  or 
where  the  prodromal  or  initial  symptoms  have  been  overlooked, 
or  have  not  been  amenable  to  treatment,  the  possibility  of  homo 
treatment  Avill  depend  mostly  on  the  patient's  means,  but  also 
partly  on  the  character  of  the  mental  affection,  and  on  the 
physical  condition  of  Lhe  suff"erer.  A  j)atient  of  strong  physique, 
with  marked  suicidal  or  homicidal  tendencies,  or  who  obstinately 
refuses  food,  will  require  a  number  of  attendants,  and  in  the 
latter  case  three,  or  at  least  two,  medical  visits  daily.  On 
the  other  hand,  cases  of  simple  melancholia,  and  of  primary 
deterioration,  of  simple  mania,  of  ordinary  acute  mania  in  non- 
muscular  persons,  of  puerperal  mania,  if  food  is  not  refused, 
of  alcoholic  insanity,  acute  or  chronic,  where  deprivation  of 
alcohol  can  be  ensured,  of  primary  confusional  insanity,  of  anergic 
stupor,  etc.,  etc.,  can  be  treated  outside  an  asylum  at  com- 
paratively little  expense,  yet  not  so  economically  as  in  one  of  these 
institutions.  Nevertheless,  the  stigma  still  attaching  to 
individuals  Avho  have  been  patients  in  asylums,  and  to  a 
greater  or  less  extent  to  their  relatives,  still  acts  as  a  strong 
deterrent  to  asylum  treatment.  Uncertified  insane  patients  must 
not  be  kept  for  profit,  even  by  relatives.  Any  uncertified 
alleged  lunatic  can  now  be  visited  by  the  Commissioners  (see 
chap,  ix.)  Home  treatment  having  been  decided  upon,  a 
detached  house  in  a  healthy,  bracing  neighboiu-hood,  hilly  or 
seaside  should  be  selected.  The  patient  should  have  two  rooms 
on  the  ground  floor,  one  as  a  sitting  room,  the  other  as  a  bedroom. 
The  latter  should  be  well  warmed  by  means  of  covered  hot  water 
coils,  the  bed  should  be  on  the  floor,  the  window  Avell  shuttered 
on  the  inside,  if  necessary  the  floor  ma}'-  be  covered  with  straw 
mattresses,  of  which  there  should  be  a  sufficient  number  to 
change  ;  all  chairs,  fire-irons,  gas-pipes,  brackets  or  ornaments 
should  be  remoA'ed.  In  the  sitting  room,  all  articles  that  might  be 
used  as  Aveapons  or  missiles  should  be  removed,  yet  at  the  same 
time  the  room  ought  not  to  be  made  too  bare  and  gloomy. 

When  forcible  feeding  is  requii-ed  for  any  length  of  time, 
it  AAdll  be  necessary  to  use  the  stomach  tube,  either  nasal  or  oral. 
The  oral  preferably,  as  by  the  nasal  method  an  alarming  amount 
of  dyspnoia,  discomfort  and  cyanosis  is  produced  even  Avhen  the 
tube  has  not  passed  into  the  larynx,  haAdng  been  guided  past  the 
fauces  and  the  laryngeal  aperture  by  means  of  stilettes,  as  in  the 
French  method.     The  nasal  tube  must  also,  to  pass  the  nostril, 


THPJRAPEUTICS   AND   HYGIENE.  200 

be  smaller  than  the  oral.  The  oral  method  having  been  selected, 
it  will  be  requisite  to  have  at  least  four  attendants  if  mechanical 
restraint  is  to  be  avoided.  If  the  patient  is  quiet,  as  in 
some  cases  of  melancholia,  he  may  be  fed"  sitting  in  a  chair,  with 
the  help  of  one  or  tw-o  attendants.  In  other  cases  the  patient 
having  been  laid  on  a  bed  on '  the  floor  with  his  head  and 
shoulders  raised  by  pillows,  one  attendant  at  the  top  should  hold 
the  patient's  head  firmly  between  his  hands,  another  should  hold 
the  arms,  and  a  third  the  legs.  When  the  patient  is  very 
obstructive  and  violent,  it  is  safer  to  have  a  restraining  or  feeding 
chair.  (In  certified  cases  the  use  of  such  a  chair  must  be 
recorded  and  reported.)  The  physician  standing  on  the  left 
side  of  the  patient  should  then  introduce  between  the  teeth 
the  closed  point  of  a  steel  screw  mouth  dilator,  by  screwing 
apart  the  points  of  which  the  mouth  may  be  widely  opened, 
and  so  retained,  the  mouth  dilator  being  now  used  as  a 
gag  and  held  by  a  fourth  attendant.  In  unresisting  toothless 
cases  no  gag  is  required.  The  physician  standing  on  the  patient's 
right  side  ^can  then  readily  introduce  a  well-oiled  soft  rubbei' 
stomach  tube  (occasionally  a  stiff  one  may  be  required),  or  a 
siphon  stomach  pump,  guiding  the  end  of  it  down  the  back 
of  the  pharynx  with  the  left  forefinger.  If  the  stomach  tube 
is  chosen,  the  fluid  food  can  be  poured  into  the  funnel-shaped 
end,  if  the  siphon,  the  funnel-shaped  end  can  be  slightly 
weighted  and  put  in  the  vessel  containing  the  food,  placed 
above  the  level  of  the  patient's  head,  and  the  fluid  introduced  by 
the  usual  method,  of  using  the  siphon  stomach  pump.  At 
first  half  a  pint  of  fluid  Avill  be  sufficient,  but  this  can  be  rapidly 
increased  to  a  pint,  a  pint  and  a  half,  or  even  a  quart,  given 
twice  or  three  times  a  day.  The  fluid  may  consist  of  milk, 
eggs,  beef  tea,  minced  and  pounded  meat,  thin  arrowroot, 
broth,  soups,  combined  in  various  proportions  according  to  the 
state  of  the  patient's  bowels,  etc.  Orange  juice,  pulp  of  grapes, 
medicine,  spirits,  wine,  etc.,  may  be  added.  It  has  been  recom- 
mended to  add  salt  in  order  to  cause  appetite  for  food. 

Minor  details. — It  is  advisable  to  run  some  tepid  water  through 
the  feeding  tube  before  using  it.  The  ends  of  the  mouth  dilator 
should  be  covered  with  clean  pieces  of  lint  each  time  it  is  used, 
and  no  permanent  india-rubber  covering  should  be  employed, 
as  it  is  liable  to  cause  inflammation,  abscess,  and  even  necrosis. 
In  introducing  it,  it  is  well  to  take  advantage  of  gaps  in  the  teeth. 
The  patient's  clothes  should  be  protected  by  a  sheet  or  serviette. 

When  the  tube  is  being  introduced  for  the  first  time  it 
generally  causes  some  cyanosis  and  appearance  of  choking,  but 
this  effect  soon  ceases,  and  the  tube  being  in  the  oesophagus  can 


256  THERAPEUTICS   AND   HYGIENE. 

he  passed  until  many  inches  of  its  length  have  disappeared,  but  if 
by  mistake  it  has  entered  the  larynx  only  a  few  inches  can 
1)6  passed.  Further,  if  the  tube  is  in  the  larynx,  air  will  be 
inspired  through  it ;  this  is  impossible  if  it  is  in  the  stomach, 
though  gaseous  matters  may  pass  out  by  the  tube  and  expiration 
be  thus  simulated. 

Krapelin  recommends  auscultation  of  the  stomach  whilst  air  is 
blown  into  the  feeding-tube  in  order  to  be  quite  certain  that  the 
latter  is  not  in  the  trachea. 

On  the  flexible  tubes  now  there  is  nearly  always  a  ring  about 
fourteen  inches  from  the  end,  and  when  this  ring  is  at  the 
patient's  lips,  the  end  of  the  tube  will  be  near  the  cardiac  orifice 
of  the  stomach.  With  soft  tubes  care  should  be  taken  that  the 
end  does  not  catch  at  the  constriction  of  the  pharynx  or  at  the 
epiglottis  or  larynx,  and  the  tube  get  coiled  up  in  the  pharynx 
and  mouth  instead  of  passing  down  the  oesophagus.  It  is 
advisable  to  have  a  stiff  tube  always  in  readiness.  In  with- 
drawing the  tube  pull  it  slowly  for  five  or  six  inches,  agitating  it 
at  the  same  time  so  as  to  empt)^  it ;  then  draw  the  end  of  it 
quickly  through  the  pharynx  and  mouth.  The  patient  should  be 
watched  for  some  time  to  prevent  him  trying  to  induce  vomiting. 
The  tube  and  gag  should  be  well  washed  and  disinfected. 

I  have  generally  found  twice  a  day  sufiiciently  often  for  forcible 
feeding.  An  emaciated  melancholiac  was  fed  only  twice  a  day  for 
many  months.  He  had  out-door  exercise  regularly.  He  gained 
over  30  lbs.  in  weight  and  came  round  to  take  food  voluntarily. 

Out-door  exercise,  in-door  amusement,  entertainments  (unless 
in  acute  cases),  occupation,  literature  of  various  kinds,  regularity 
of  meals  and  sleeping  hoiu's,  attention  to  gastro-intestinal 
functions,  saitable  clothing,  kind  and  gentle,  yet  firm  treatment, 
are  absolutely  necessary.  Some  useful  employment  on  a  farm 
or  garden,  or  in  workshops,  kitchen,  laundry,  or  bedrooms,  is 
very  beneficial,  and  has  proved  curative  in  many  cases.  Most 
asylums,  private  as  well  as  public,  have  now  adopted  this  system 
to  a  greater  or  less  extent. 

The  patient's  morbid  ideas  and  fixed  delusions  should  never  be 
agreed  with,  and  it  is  almost  useless  to  contradict  them ;  there- 
fore, the  best  plan  is  to  turn  the  subject  as  soon  as  possible, 
or  di^'ert  the  patient's  attention  to  some  amusement  or  occupation. 

The  non-medicinal  or  mental  or  moral  treatment  is  of  extreme 
value.  The  condition  of  the  psychical  atmosphere  (the  impres- 
sions on  all  the  senses  including  the  muscular)  is  as  important 
to  the  patient  whose  cerebral  structiue  is  diseased  as  the  physical 
atmosphere  is  to  the  suiferer  from  pulmonary  mischief.      The 


THERAPEUTICS   AND    HYGIENE.  25/ 

highest  mental  faculties  are  formed  out  of  the  lowest,  and  these 
are  easily  accessible.  It  is  therefore  only  reasonable  to  expect 
that  in  derangement  of  the  former  the  latter  will  be  capable 
of  being  acted  upon  so  as  to  influence  the  former  beneficially. 
In  addition  to  the  methods  already  mentioned  of  acting  on  the 
brain  through  the  senses,  the  influence  of  music  and  of  coloured 
light  (blue  depressing,  red  exciting)  should  not  be  forgotten. 
Cerebral  localisation  might  also  be  brought  to  bear.  W.  Carter 
reports  ("  Liverpool  Med.  Chi.  Jour.")  a  case  of  aphasia  rapidly 
cured  by  verbal  re-education,  combined  with  constant  use  and 
vigorous  exercise  of  the  left  arm  and  hand.  A  system  of  education 
might  be  useful  in  the  psychoses  as  well  as  in  aphasia  and  idiocy. 
Sollier  ("Progres  Medical")  says  the  recovery  rate  in  the  French 
provincial  asylums  has  fallen  in  a  few  years  from  27  to  20.  He 
thinks  this  low  recovery  rate  (about  half  the  English)  is  owing 
principally  to  the  neglect  of  non-medicinal  treatment.  In  one 
English  institution,  Barnwood  House  Hospital  for  Mental  Diseases, 
the  recovery  rate  as  shown  by  the  last  report  is  68  per  cent. 
Recovery  rates  are  calculated  on  the  yearly  admissions. 

Hypnotics  should  only  be  used  occasionally,  and  the  same  may 
be  said  of  calmatiA^e  medicines.  When  the  patient  is  "wet  and 
dirty,"  he  should  be  frequently  taken  to  the  night  chair  or  closet, 
and  wet  or  soiled  clothes  ought  to  be  changed  immediately. 
Retention  of  urine  should  be  watched  for,  and,  in  fact,  the  medical 
man  should  investigate  the  state  of  the  internal  organs,  including 
the  abdominal  and  pelvic  viscera,  every  alternate  day,  for  the 
patient  may  be  "  wet  "  or  even  "  dirty  "  whilst  urine  is  accumu- 
lating in  the  bladder,  and  the  bowels  are  becoming  loaded  with 
scybala,  and  there  may  be  serious  thoracic  mischief  without  the 
usual  subjective  signs  such  as  pain,  cough,  dyspnoea. 

B. — Private  Care   (Single  Patients). 

Under  this  head  are  included  cases  kept  in  unlicensed  houses, 
preferably  the  residences  of  medical  men,  for  a  consideration. 
Formerly,  only  one  case  could  be  taken  care  of  in  this  way, 
but  by  the  Lunacy  Act  of  1890  the  commissioners  can  give  per- 
mission for  more  than  one  insane  patient  to  be  kept  in  an 
imlicensed  house.  Every  person  of  unsound  mind  in  such  paid, 
private  care  mvist  be  duly  certified  in  accordance  Avith  the 
provisions  of  the  new  Lunacy  Acts   (see  next  chapter). 

Weatherly  ("The  Care  and  Treatment  of  the  Insane  in  Private 
Dwellings")  considers  the  follomng  cases  suitable  for  this 
method  of  treatment.  Many  cases  of  simple  melancholia,  some 
cases  of  acute  primary  dementia  (anergic  stupor),  cases  of  acute 
delirious    mania     (acute    delirium),    semi-insane    persons    with 

17 


258  THERAPEUTICS   AND   HYGIENE. 

exaggerated  eccentricities,  but  free  from  dangerous  habits,  the 
majority  of  cases  of  recurrent  mania,  harmless  chronic  cases  of 
insanitv,  convalescing  patients,  and  "  almost  all  cases  of  insanity 
in  the  early  stage,  except  those  coming  under  the  head  of  acute 
mania,  acute  melancholia,  melancholia  vrith  stupor,  erotomania, 
and  cases  haAing  distinct  homicidal  and  suicidal  tendencies  .... 
proA-ided,  of  course,  that  adecjuate  means  of  properly  caring  for 
them  are  present.  AVith  regard  to  chronic  cases  of  mental 
disease,  the  cases  I  consider  unsuitable  for  domestic  treatment — 
or  rather  care — are  those  of  homicidal  and  suicidal  mania,  melan- 
cholia "vnth  stupor,  general  paralysis  of  the  insane,  epileptic 
insanity  and  erotomania,  and  also  some  of  the  many  cases  of 
idiocy  and  imbecility."' 

But  Avhere  the  patient's  means  are  adecjuate,  any  form  of 
insanity  may  be  treated  in  this  way,  as  in  that  case  the  retjuisitc 
niunber  of  attendants  may  be  retained,  padded  rooms  fitted  iip, 
caniage  exercise  and  other  means  of  recreation  oljtained,  and 
imlimited  changes  of  clothing  provided.  Erotic  tendency  may 
be  controlled  by  the  bromides,  or  where  the  patient  is  not  strong 
physically,  by  the  liquid  extract  of  salix  nigra.  With  regard  to 
mechanical  restraint,  this  is  seldom  resorted  to  in  the  bes*: 
asylums,  and  then  only  for  surgical  reasons  or  to  prevent  self- 
injury.  It  may  be  least  injuriously  effected  by  means  of  leather 
gloves,  fastening  at  the  wrist,  care  being  taken  that  they  do  not 
abrade  the  skin,  each  glove  having  a  loop  running  on  a  belt 
loosely  worn  roimd  the  waist.  Or  by  means  of  the  camisole, 
.suggested  by  Magnan  ("Camisole.  Eecherches  siu"  les  Centres 
Nerveux'"'")  which  consists  of  a  kind  of  combination  suit,  the  long 
sleeves  being  attached  by  straps  to  the  outside  of  the  trousers 
instead  of  being  tied  round  the  chest,  as  in  the  ordinary  straight 
waistcoat.  By  5lagnan's  method  respiration  is  not  interfered  with. 
It  should,  however,  be  remembered  that,  according  to  Section  40 
of  the  Lunacy  Act  1890,  "  mechanical  means  '  of  restraint  are 
to  be  "  such  instruments  and  appliances  as  the  Commissioners 
may,  by  regulations  to  be  made  from  time  to  time,  determine." 

►Seclusion,  meaning  fastening  a  patient  in  a  room  by  himself 
between  7  a.m.  and  7  p.m.  ("compidsory  isolation  in  the  day- 
time ")  can  very  rarely  have  the  excuse  in  domestic  care  put 
forward  for  its  use  in  asylums,  "viz.,  the  remoA'al  of  the  patient 
from  the  propinquity  of  exciting  and  excitable  fellow-patients,  but 
when  resorted  to  must,  like  restraint,  be  entered  in  the  medical 
visitation  book  ("  Medical  Journal  '")  by  the  medical  attendant, 
who  must  there  state  the  time,  duration,  means,  and  reason.s 
(see  chap.  IX).  Shower  baths  and  j^limge  baths,  which  should 
never  be  used  as  instruments  of  torture,  are  frequently  asked  for 


THERAPEUTICS   AND    HYGIENE.  259 

by  patients,  and  either  the  latter  or  sponge  baths  for  the  purposes 
of  cleanliness,  are  almost  indispensable.  In  cases  of  masturba- 
tional  insanity,  primary  mental  deterioration,  simple  melancholia, 
and  acute  mania,  a  short  shower  bath  vrHl  often  do  good.  Cold 
baths  are  useful  in  general  paralysis  (vide  infra). 

In  acute  delirium  and  senile  insanity  a  warm  bath  of  half-an- 
hour  to  an  hour's  duration  will  often  procure  sleep  without 
medicine  or  other  means,  or  "with  the  help  only  of  some  warm  beef 
tea  and  spirits. 

A  patient  not  actually  residing  in  the  house  of  a  medical  man 
should  have  constant,  and  if  possible,  resident  medical  supervision. 
The  medical  attendance  should  not  be  limited  to  the  statutory 
fortnightly  visit.  Before  undertaking  the  treatment  of  such  a  case 
the  practitioner  ought  to  have  a  distinct  understanding  that  the 
attendants  are  to  be  under  his  sole  direction  and  obedient  to  him. 
This  is  absolutely  necessary,  as  however  amenable  to  discipline 
attendants  may  be  Avhen  employed  in  an  asylum,  they  are  liable 
to  become  too  independent  when  nursing  single  patients. 

C. — Asylum  Treatment. 
Asylums  are  divided  into — 
1. — pauper  asylums. 

2. — LUNATIC   hospitals. 

3. — licensed  houses  or  private  asylums. 

1 . — Fa  uper  asi/lums. 

Under  this  head  may  for  practical  purposes  be  included  county 
and  borough  asylums,  criminal  asylums,  and  the  lunatic  wards  of 
workhouses.  In  Ireland  many  of  the  public  asylums  are,  or 
rather,  were  designated  "  District  Hospitals  for  the  Insane."  In 
the  United  States  some  of  them  are  more  happily  called  "  State 
Hospitals."  (The  name  of  a  public  institution  might  seem  to  be 
of  little  importance,  but  as  a  matter  of  fact,  respectable  working 
men  complain  bitterly  that  letters  from  or  about  their  relatives  in 
some  of  the  English  county  asylums  have  their  envelopes 
endorsed  i^ro  bono  publico,  ^\\Xh  the  words  "  County  Asylum"). 
This  is  the  only  form  of  treatment  available  for  the  poorer 
classes,  and  even  for  many  persons  belonging  to  the  profes- 
sional class.  In  these  large  public  establishments  patients 
have  the  advantage  of  discipline,  the  example  of  patients  once 
troublesome,  noAv  settled  down,  extensive  farm  and  gardens, 
varied  occupation  and  amusements.  On  the  othei-  hand,  some  of 
the  institutions  contain  too  many  patients  under  one  medical 


260  THERAPEUTICS   AND   HYGIENE. 

superintendent,  and  the  medical  staff  is  numerically  inadequate  to 
perform  the  amount  of  work,  clerical  and  other,  expected  of  it, 
and  at  the  same  time  to  allow  its  members  to  study  their  cases 
clinically  da-y  by  day,  as  in  other  special  hospitals.  Some  of  the 
county  asylums  now  take  private  patients  at  moderate  weekly 
payments.  Even  when  the  patient  has  been  made  a  pauper, 
his  friends  are  permitted  or  required  to  contribute  to  his 
maintenance  if  they  are  in  a  position  to  do  so. 

It  wovild  be  a  great  advantage  to  the  clinical  study  of  mental 
diseases  if  all  recent  cases  of  insanity  drawn  from  the  poorer 
classes  were  first  received  in  hospitals  or  asylums  like  St.  Anne's,  in 
Paris  (but  situated  just  outside  the  large  towns  and  with  adequate 
farms,  etc.),  whence  they  could  be  forwarded  to  the  larger 
asylums,  only  those  being  retained  whose  illness  would  probably 
be  of  short  duration,  or  who  were  required  for  special  study 
and  treatment.  St.  Anne's,  where  considerable  numbers  of  newlj'^ 
admitted  jDatients  are  seen  and  carefully  examined  by  the 
physicians  every  morning  in  the  presence  of  the  pupils,  forms  an 
excellent  training  school,  especially  when  taken  in  conjunction 
with  the  opportunities  for  pathological  stiidy  afforded  by  the 
chronic  cases  of  the  Salpetriere  and  Bicetre.  In  Vienna,  a  portion 
of  the  A^ery  large  general  hospital  is  devoted  to  the  reception  and 
treatment  of  insane  patients.  This  is  convenient  for  clinical 
instruction,  but  does  not  seem  to  me  to  be  the  most  beneficial 
arrangement,  so  far  as  the  patients  are  concerned.  There  was  at 
one  time  an  insane  ward  in  Guy's  Hospital,  but  it  was  not  a 
success.  Most  of  the  insane  need  ample  space  for  recreation  and 
work. 

"  Every  public  asylum  should  be  available  for  scientific  research 
and  clinical  teaching  of  insanity  to  students  of  medicine,  and  to 
qualified  practitioners  "  (Care  and  Treatment  Committee,  Med. 
Psych.  Assoc).  It  is  also  recommended  by  the  same  committee 
that  provision  should  be  made  for  the  treatment  of  oiit-patients  ; 
that  Recent  Cases  should,  unless  obviously  incurable,  be  received  in 
a  special  ward  or  block,  or  Ijuilding ;  that  there  should  be  a 
special  Infirmary  ttxird  or  block. 

2. — Lunatic  Hospitals. 

The  inmates  of  these  institutions  are  derived  from  the  upper 
and  middle  classes,  and  the  terms  vary  from  £500  or  even  £1000 
a  year  to  ten  shillings  a  week,  although  there  are  very  few 
paying  the  latter  sum  or  anything  near  it.  The  ordinary  payments 
are  from  1|^  to  6  guineas.  Originally  intended  for  middle 
class  patients  whose  friends  dislike  the  idea  of  sending  them 
to  pauper  asylums,  they  have  now  come  to  compete  with  the 


THERAPEUTICS   AND   HYGIENE.  261 

highest  class  of  private  asylums.  As  instruments  of  treatment 
for  the  curable,  and  as  homes  for  the  incurable,  they  are  excellent. 
Some  of  them  have  several  villa  residences  in  their  grounds  where 
the  patient,  if  necessary,  can  live  apart  from  other  sufferers 
and  yet  remain  under  the  supervision  of  the  medical  superin- 
tendent and  his  staflF.  The  grounds,  farm  and  gardens  are 
generally  extensive.  The  number  of  inmates  conduces  to  the 
frequency  of  associated  entertainments  and  amusements  such  as 
concerts,  dances,  theatrical  performances,  cricket,  tennis,  bowls, 
golf,  boating  parties,  etc.,  etc.,  as  well  as  cards,  billiards,  chess, 
draughts,  dominoes.  These  asylums  are  managed  by  boards 
•of  governors,  and  the  receipts  are  all  exj)ended  on  the  patients  or 
the  buildings  in  which  they  live.  The  medical  superintendent  is 
a  salaried  official,  and  the  governors  derive  no  pecuniary  profit 
whatever  from  the  institution.  These  establishments  are  visited 
and  carefully  inspected  twice  a  year  by  the  Commissioners  in 
Lunacy. 

Voluntary  boarders  who  have  never  JDeen  in  an  asylum,  can  be 
taken,  so  that  facilities  may  be  given  for  the  treatment  of  in- 
cipient cases  of  insanity  where  the  patient  feels  his  own  weakness. 
Although  very  advantageous  for  the  treatment  of  those  who  can 
afford  the  terms,  there  is  something  else  wanted  for  poor  pro- 
fessional men,  clerks,  and  tradesmen  who,  recoiling  from  making 
their  relatives  paupers,  yet  cannot  afford  to  pay  the  (to  them) 
large  sums  required  by  the  lunatic  hospitals  and  private  asylums 
of  the  present  day. 

A  few  asylums  placed  near  the  large  centres  of  population  and 
built  to  accommodate  about  200  patients,  the  payments  varying 
from  a  minimum  of  five  shillings  a  week  to  a  maximum  of  fifteen, 
inclusive  of  everj^thing,  would  meet,  to  use  a  hackneyed  expression, 
"  a  long-felt  want." 

That  in  addition,  there  should  be  separate  asylums  for  dipso- 
maniacs and  drunkards  who  have  not  yet  deteriorated  into 
chronic  alcoholic  lunatics,  I  think  anyone  will  admit  who 
has  had  experience  of  inebriate  cases  in  private  asylums  and  in 
private  outside  practice  ;  and  that  further,  the  patient  should 
under  certain  circumstances  be  compelled  to  enter  such  an  asylum 
for  a  given  time  ;  the  time  to  be  extended  afterwards,  if  necessary, 
by  the  medical  and  legal  authorities ;  and  lastly,  that  these 
asylums  for  inebriates  should  not  be  kept  for  gain  but  be 
established  on  the  original  lines  of  the  present  lunatic  hospitals. 

3. — Private  Asylums  (Licensed  Houses). 

Bucknill  and  Tuke  (p.  650)  are  of  opinion  that  whilst  small 
asylums  may  do  for  chronic  lunatics,  for  the  curative  treatment 


262  THERAPEUTICS   AND    HYGIENE. 

of  recent  cases  "  an  asylum  (including  under  this  term  lunatic 
hospitals  and  licensed  houses)  containing  at  least  thirty  or  forty 
patients  should  be  chosen,  and  one  containing  four  or  five  times 
that  number  should  be  preferred.  A  certain  minimum  number 
of  fellow-patients  is  needful  to  establish  thac  system  of  method 
and  discipline  which  forms  a  great  part  of  the  curative  influence 
of  asylum  treatment."  Where  the  patient's  means  are  only 
moderate,  he  "svill,  if  very  troublesome,  be  better  treated  in 
an  asylum  than  under  domestic  or  private  care.  Under  the  head 
of  troublesome  would  come  cases  of  acute  mania,  acute  melan- 
cholia, persecutory  delusional  insanity  (persecutional  paranoia), 
most  cases  of  general  paralysis,  cases  with  strong  suicidal, 
homicidal  or  erotic  tendencies,  and  cases  that  are  per.sistently 
wet,  dirty  or  destructive. 

It  is  best  to  select  an  asylum  in  Avhich  the  medical  superin- 
tendent exercises  undivided  control.  The  asylum  should  not  be 
so  near  the  patient's  home  as  to  interfere  with  his  walks,  drives, 
etc.  ;  nor  yet  so  far  from  his  relatives  as  to  make  ^dsiting  incon- 
venient for  them. 

That  many  patients  are  very  comfortable  in  these  establishments 
is  proved  by  the  facts  that  those  who  recover  frequently  re-visit 
them  when  well ;  that  some  patients  return  of  their  OAvn  accord 
when  they  begin  to  feel  ill,  getting  themselves  medically  certified, 
or  retiu'ning  as  voluntary  boarders ;  that  many  old  chronic 
jDatients  elect  to  remain  inmates  of  these  asylums  rather  than  be 
removed  to  their  homes  or  to  other  institutions. 

Wherever  treated  the  patient  should  be  allowed  as  much 
liberty  as  is  compatible  with  safety  (in  Scotland  the  open-door 
system  is  being  successfully  carried  out  in  several  asylums  J ;  when 
convalescent,  he  ought  to  be  permitted  to  go  about  on  parole, 
and  before  l^eing  lega'ly  discharged,  he  should  be  allowed  to  go 
out  on  probation ;  he  should  not  be  sent  immediately  to  the 
locality  where  he  became  ill,  and  should  not  be  allowed  at  once 
to  resume  his  avocation. 

The  formation  of  After-Care  Associations  is  a  step  in  the 
right  direction.  These  are  doing  good  work  on  the  Continent 
and  in  London. 

The  Gheel,  or  insane  village  system,  if  it  could  be  established 
in  this  country,  would  be  a  gTeat  improvement  on  asylum 
treatment  so  far  as  many  insane  patients  are  concerned. 

■    Treatment  of  special  forms  of  Insanity. 

Choreic  Insanity. — Dresch,  Pianese  and  others,  think  chorea  is 
microbic,  and  use  sodii  salicvl.  as  a  bactericide. 


THERAPEUTICS   AND   HYGIENE.  263 

Climacteric,  Adolescent,  Pubescent,  Masturbational  and  Senile 
Insanity  are  benefited  by  the  bromides,  piscidia  erytbrina,  and 
salix  nigTa  (see  cbap.  VII.). 

Coarse  Brain  Disease  (Insanity  from)  may  in  some  cases  (arising 
from  abscesses,  tumours,  spicula,  etc.)  be  benefited  by  cranial 
operations  based  on  cerebral  localisation.  Since  1876  Macewen 
has  performed  successfully  many  such  operations  for  the  relief 
of  various  conditions  and  symptoms.  Bergmann  has  also  operated 
successfully.  In  cases  of  brain  tumour,  Horsley  urges  that  after 
pot.  iodid.  has  been  given  in  large  doses  for  six  ^veeks  -without 
very  notable  and  real  improvement,  exploratory  operation  shoidd 
be  resorted  to.  It  affords  relief  even  if  cure  by  removal  is 
impossible  ("Brit.  Med.  Jour.").  Hack  Tuke  ("The  Influence 
of  the  Mind  upon  the  Body,"  p.  413)  reports  some  of  Braid's 
cases  in  which  organic  paralysis  was  diminished  or  cured  by 
hypnotism.  In  cerebral  haemorrhage  Horsley  ach'ocates  pressure 
on  or  ligature  of  the  common  carotid,  De  Watteville  recommends 
electricity,  and  W.  Carter  ("Liverpool  Med.  Chi.  Jour.")  small 
doses  of  morphia.  Hayes  Agnew,  speaking  from  the  experience 
of  the  Philadelphia  surgeons,  advocates  trephining  in  cerebral 
al)scess  and  in  intra-cranial  traumatic  hgemorrhage  ("  Prov.  Med. 
.lour."). 

Delirium  (Acute). — Most  authors  advise  that  hypnotics  and 
sedatives  should  be  used  carefully  and  sparingly  if  at  all. 
The  patient  should  have  warm  baths  of  half-an-hour  to  an  hour's 
duration  at  bedtime,  cold  being  applied  to  the  head  and  a  careful 
watch  kept  by  the  medical  attendant  during  the  time  the  patient 
is  immersed.  The  patient  must  have  abundant  fluid  food,  milk, 
eggs,  beef  tea,  etc.,  given  forcibly  if  not  taken  voluntarily.  He 
should  be  kept  in  bed  in  a  darkened  room,  the  windows  being 
well  guarded,  and  everything  that  might  cause  irritation  or  injury 
removed. 

When  the  baths  cannot  be  given,  packing  in  a  warm,  wet  sheet, 
with  blankets  over  all  may  be  substituted,  col  cl  as  before  being: 
applied  to  the  head. 

Acute  maniacal  cases  tending  towards  acute  delirium  should  be 
treated  in  much  the  same  way.  The  object  is  to  relieve  cerebral 
congestion,  whilst  at  the  same  time  maintaining  the  physical 
strength. 

Epilepsy  and  Epileptic  Insanity.- — The  bromides  are  still  the  sheet 
anchor  in  the  treatment  of  the  neurosis,  and  frequently  beneficial 
in  the  excitement  and  irritability  occurring  in  the  psychosis. 
Their  good  effects  are  increased  and  their  deleterious  ones 
diminished  or  avoided  by  inter: ombination,  and  by  the  simij.- 
taneous  administration  of  such  therapeutic  agents  as  arsenic,  zinc, 


264  THERAPEUTICS   AND   HYGIENE. 

the  carbonates,  ammonia,  the  iodides,  cannabis  indica,  cascara 
sagrada,  bark,  bitter  limes. 

Borax,  in  initial  doses  of  10  grains  three  times  a  day,  occasionally 
succeeds  when  the  bromides  fail.  Mairet  ("  Prog.  M6d.")  recom- 
mends borax  where  there  is  coarse  brain  disease,  and  the  bromides 
in  idiopathic  epilepsy.  In  children  I  have  found  equal  parts  ot 
the  three  bromides  with  liq.  cascar.,  suavis  and  syr.  senn.,  act 
well.  Potts  and  Wood  give  (to  adults)  gr.  6  of  antipyrin  and 
gr.  20  of  amm.  bromid.  three  times  a  day  with  good  results 
("  Braithwaite's  Retrospect"). 

In  the  treatment  of  the  neurosis  Alexander  recommends 
percussion  of  the  spine  ;  electricity  to  the  spine  ;  the  removal  of 
causes  of  irritation,  gastric,  intestinal  or  other  ;  trephining  over 
the  seat  of  injury  in  traumatic  cases ;  shortening  the  round  liga- 
ments (Alexander's  operation)  in  suitable  cases  of  uterine  flexion  : 
no  stimulants  or  tol^acco,  or  as  little  as  possible ;  a  mild  nutritious 
diet.  Removal  of  the  superior  cervical  ganglia  of  the  sympathetic  ; 
of  twenty-four  cases  operated  on  by  Alexander  during  a  period  of 
four  to  six  years,  six  were  cured,  ten  im2:)roved,  esj)ecially 
mentally  ;  five  unimproved  ;  two  died  ;  and  one  was  lost  sight  of 
("The  Treatment  of  Epilepsy,"  1889). 

Jacksonian  epilepsy,  arising  from  gross  lesions,  has  been  fre- 
quently cured  by  means  of  cerebral  surgical  operations. 

Leonte  and  Bardesco  consider  that  trephining  is  indicated 
where  monoplegia  and  convulsions  co-exist,  and  that  it  should  be 
done  early  ("Brit.  Med.  Jour.,"  ISov.,  1891). 

The  results  of  the  excision  of  the  epileptogenous  focus  in  cases 
of  focal  epilepsy  without  gross  lesion,  an  operation  first  performed 
by  Horsley,  are  distinctly  encouraging,  both  as  to  the  fits  and  the 
mental  condition,  the  improvement  in  the  latter  being  immediate 
and  progressive  ("Brit.  Med.  Jour.") 

Keen  says  the  results  of  cortical  excision  have  been,  on  the 
whole,  very  encouraging  in  traumatic  epilepsy  ("Braithwaite's 
Retrospect,"  July,  1891). 

In  the  status  epileptims,  cathartic  drugs  or  enemata  ;  inhalation 
of  chloroform,  or  administration  of  chloral  and  bromides  by 
mouth  or  rectum. 

Exophthalmic  Goitre  (Insanity  of). — For  exophthalmic  goitre  ; 
galvanism,  place  positive  pole  in  sub-aural  space  and  apply  mild 
labile  current  from  negative  over  goitre  and  closed  eyelids. 
Three  to  ten  milliamp^res,  three  to  five  minutes  daily  ("  Medical 
Annual,"  1889,  p.  124).  CardeAV  ("Lancet,"  April  7th,  1891) 
uses  a  current  of  a  still  lower  maximum  strength  for  six  minutes 
three  times  a  day.  He  applies  the  anode  to  nape  of  neck 
and  moves  the  kathode  up  and  down  side  of  neck. 


'     THERAPEUTICS   AND   HYGIENE.  265 

General  Paralysis  of  the  Insane. — To  give  any  reasonable  chance 
of  success  the  prodromata  mnst  be  attacked  ;  the  cause,  if  j)ossible, 
removed,  change  of  scene,  rest,  etc.,  prescribed. 

Medicines. — Crichton-Brown  has  found  benefit  in  the  developed 
disease  from  the  administration  of  physostigma  faba.  Julius 
Mickle  formerly  recommended  tinct.  fer.  perchlor.,  but  latterly 
has  given  full  doses  of  pot.  iodid.,  with  or  without  small  doses 
of  bromide,  treatment  which  seems  to  ameliorate  somewhat 
the  condition  of  the  patient,  diminishing  excitement  and 
pain.  He  still  gives  iron  when  the  patients  are  feeble,  or  quiet, 
or  in  the  later  stages  of  the  disease.  Boubila  ("  Mercredi 
Medical ")  strongly  recommends  the  chloride  of  gold  and  sodium, 
TOT  to  1^-0  of  a  gramme. 

Otiier  Measures. — Magnan  treated  a  number  of  patients  at 
St.  Anne's  thirteen  years  ago  by  applying  tartar  emetic  ointment 
to  the  scalp  at  short  intervals  of  time  until  a  deep  sore  was  pro- 
duced, but  the  results  were  not  encoiu-aging.  Lately  Claye  Shaw 
has  treated  two  cases  with  apparent  benefit  at  Banstead,  by 
trephining;  and  he  quotes  another  case  from  the  Brookwood 
Asylum  in  which  this  operation  was  followed  by  "  marked  relief 
to  several  prominent  symptoms"  ("Brit.  Med.  Jour.,"  Sept., 
1891).  Key  ("Progres  Medical,"  15  Aoiit,  1891)  trephined  in 
a  case ;  the  patient  was  able  to  return  home  in  a  month  and 
a  half,  and  remained  calm  and  quiet. 

Voision  recommends  cold  baths.  So  does  Meynert,  in  the 
early  stages. 

As  general  paralysis  is  primarily  a  vasa-motor  disease  and 
secondarily  one  of  connective  tissue  proliferation,  it  would  seem 
a  priori  that  vascular  constringents,  such  as  ergot,  strychnine, 
pot.  bromid.,  quinine,  antipyrin,  etc.,  ought  to  be  beneficial  in  the 
incipient  stage  of  the  disease,  Avhilst  hyclrarg.  perchlor.  (as  a 
resolvent  of  connective  tissue)  combined  perhaps  with  pot.  iodid. 
should  do  good  in  the  later  stages. 

Hysterical  Insanity. — Cases  have  been  reported  ("Jour.  Nerv. 
and  Ment.  Dis.,"  etc.)  in  which  hypnotism  has  effected  a  cure. 
De  Watteville  says  electricity  may  be  used  as  a  remedial  agent  in 
the  neurosis  ("Medical  Electricity,"  p.  174). 

Idiocy  and  Imbecility. — Many  of  these  patients  are  much  im- 
proved by  the  system  of  education  now  adopted  in  the  idiot 
asylums,  but  there  is  still  a  lack  of  facility  for  the  treatment 
of  children  suffering  from  epileptic  idiocy.  In  two  cases  of  micro- 
cephalus  operated  on,  one  by  Ijannelongue,  the  other  by  Horsley, 
there  was  marked  improvement  after  craniectomy.  Other  cases 
have  not  done  so  well  ("Brit.  Med.  Jour.,"  Sept.,  1891). 
McClintock  has  recently  operated  successfully. 


266  THERAPEUTICS   AND   HYGIENE. 

Melancholia. — Opium  (including  its  preparations  and  deriva- 
tives) so  strongly  recommended  in  the  treatment  of  this  affection 
has  been  discarded  by  Clouston,  Julius  Mickle  and  other  authors, 
and  many  other  alienists.  In  active  melancholia  Krafft-Ebing 
strongly  recommends  morphia  and  the  aqueous  extract  of  opium 
hypodermically,  the  latter  to  be  preferred  for  its  trophic  action, 
Avhere  nutrition  has  failed.  Wilks  also  recommends  the  use 
of  opium.  Fide  supra  as  to  opinions  of  Blandford,  Tellegen,  etc. 
Kiernan  has  found  quebracho  act  very  beneficially  in  cases 
accompanied  by  prsecordial  pain.  Clouston  extols  the  use 
of  quinine  in  melancholia.  Meynert  advocates  the  exhibition  of 
iron,  quinine,  amyl  nitrite,  and  (when  there  is  exudation)  saline 
duu'etics. 

Myxoedema  (Insanity  of). — The  "British  Medical  Journal," 
Xov.  29th,  1890,  reports  a  case  of  grafting  the  thyroid  of  an 
animal  for  myxedema  in  Paris  by  AValther.  The  gTafting  was 
performed  under  the  right  breast  of  a  woman  of  40.  The 
operation  was  followed  by  considerable  improvement,  speech 
became  clearer,  and  the  gait  much  better.  Murray  has  found 
hypodermic  injections  of  an  extract  of  the  thyroid  gland  of  a  sheep 
to  be  followed  by  improvement  ("Brit.  Med.  Jour.,"  Oct.,  1891). 

Neurasthenia. — Krafft-Ebing  recommends  a  nutritious  diet,  rich 
in  protein  and  fat;  the  use  of  tonics  in  the  widest  sense  of 
the  word  ;  aerotherapy  (residence  on  mountains) ;  hydro-therapy 
(rubbing,  fresh  and  salt  water  baths,  etc.) ;  electricity  (general 
faradisation,  electric  baths,  etc.)  :  iron,  arsenic,  strj^chnine,  phos- 
phorus, ergot,  opium,  zinc,  cocaine,  damiana,  or  cjuinine, 
according  to  the  case ;  as  sedatives,  piscidia  erythrina  (fluid 
extract)  and  the  bromides  ;  as  hypnotics,  paraldeh^-de  in  the  first 
place,  then  amylene  hydrate,  and  sulphonal  ;  chloral  hydrate 
should  ver}'  seldom  be  used  ;  in  neurasthenia  gastrica,  forcible 
feeding  may  l)e  required.  In  7ieurasthenic  masfurbaton/  melancholia; 
tonics  with  opium  ;  hydro-therapeutic  treatment ;  careful  over- 
sight to  guard  against  masturbation. 

In  neurasthenic  insanity  from  fixed  ideas  (folie  du  doute,  partial 
emotional  abeixation,  etc.) ;  baths,  cold  and  sea  ;  climatic  treat- 
ment ;  general  faradisation ;  tonic  medicines,  iroUj  quinine, 
ergotin,  arsenic.  For  the  mental  suffering,  company,  travelling, 
diversions,  agreeable  and  pleasant,  yet  not  arduous,  occupation. 
The  cerebral  impressionability  is .  further  diminished  by  pot. 
bromid.,  5j-5jss  daily.  During  the  attacks,  pot.  brom.,  5jss-3ijss, 
morphia  injections,  chloral  hydrate,  alcohol,  consoling  assurances 
by  some  trusted  friend. 

In  neurasthinic  masturhatonj paranoia,  moi^phia  and  pot.  bromid. 
act  beneficially  on  the  hypersesthesise,  paralgiae,  and  hallucinations. 


THERAPEUTICS   AND   HYGIENE.  267 

The  five  essential  points  in  Weir-Mitchell's  treatment  of  neu- 
rasthenia are:  (1,)  Seclusion;  (2,)  Rest;  (3,)  Massage;  (4,) 
Electricity ;  (5,)  Dietetics  and  Therapeutics.  Rest  in  bed  for  six 
weeks  or  two  months.  Massage  for  six  weeks  at  least.  Diet  at 
first  skimmed  milk  and  beef  tea ;  eggs,  oysters,  brandy,  meat, 
bread,  butter,  etc.,  to  be  added  in  a  few  days  (Stretch  Dowse, 
"Massage"). 

Paranoia. — KrafFt-Ebing  recommends  the  use  of  morjahia  in 
certain  cases  (see  "'  Relief  of  Symptoms ").  In  six  cases 
(paranoia,  dementia,  and  paranoia  passing  into  dementia) 
Burckhardt  opened  the  skull  and  removed  a  portion  of  the 
cortical  gray  substance  with  a  sharp  spoon.  In  the  majority 
of  the  cases  the  most  troublesome  symptoms  (abusiveness, 
aggressiveness,  hallucinations)  were  relieved.  One  patient  died 
of  convulsions  six  days  after  the  operation  (ablation  of  portion 
of  temporo-sphenoidal  cortex).  In  another,  ablation  of  portions 
of  the  right  superior  parietal  and  supra  marginal  gyri  (see 
"Morbid  Anatomy  of  Symptoms")  caused  paralysis  of  the  left 
arm,  lasting  several  weeks,  and  transitory  paresis  of  the  left  leg 
("Jour.  Ment.  Sci.,  Oct.,  1891). 

Pellagra  and  Pellagrous  Insanity. — Arsenic  has  been  found  useful. 

Puerperal  Insanity. — Maintain  strength  by  giving,  if  necessary 
forcibly,  abundance  of  milk,  raw  eggs,  beef  tea,  port  wine,  etc. 
The  bromides,  chloral  and  other  depressants  should  be  avoided. 
Two  cases  of  mine  have  done  well  in  private  practice  with 
10  grains  of  salol  and  5  of  quinine,  given  every  six  hours, 
5SS  of  sulphonal  in  hot  milk  every  evening,  and  ni.x  tinct.  cannab. 
ind.  every  four  hours  ;  the  vagina  being  at  the  same  time  syringed 
twice  daily  \yiih  a  warm,  weak  solution  of  permanganate  of 
potash.  In  both  these  cases  the  temperature  was  supra-normal, 
and  the  lochia  were  offensive. 

Syphilitic  Insanity. — Give  from  10  to  30  grains  of  pot.  iodid. 
three  times  a  day,  preferably  the  latter  dose  in  a  tumblerful 
of  milk  two  hours  after  food,  the  dose  being  preceded  by  a  little 
brandy  if  there  is  a  tendency  to  coryza.  The  dose  may  be  in- 
creased to  100  grains  or  more,  and  mercury  may  at  the  same 
time  be  given  either  hypodermically  or  epidermically. 

Toxic  Insanity. — (1,)  Remove  the  cause  ;  (2,)  Eliminate  the 
poison  by  aperients,  diaphoretics,  diuretics,  and  in  the  case  of 
lead,  pot.  iodid.;  (3,)  Procure  sleep  by  chloral;  (4,)  Maintain 
the  strength  by  diet  and  tonics  ;  (5,)  Allay  excitement  by  means 
of  baths,  amm.  bromid.,  cannab.  indica,  digitalis  ;  (6,)  In  alcoholic 
and  opium  insanity  endeavour  to  diminish  the  cr-ave  ;  in  the  case 
of  the  former,  capsicum  and  gentian  are  of  some  benefit.  Kola 
nut   and   red    cinchona    obtained   a   reputation   which   has  not 


268  THERAPEUTICS   AND   HYGIENE. 

been  maintained.  Strychnine  has  been  used  with  success  subcu- 
taneously  in  full  doses  for  the  alcoholic  crave,  and  in  delirium 
tremens. 

Delirium  Tremens. — Kraift-Ebing  cautions  against  debilitating 
measui^es.  The  indications  are  to  maintain  the  strength  and  pro- 
cure sleep.  To  fuliil  the  former  giA^e  milk  diet,  and  in  complica- 
'  ting  or  febrile  cases,  add  Tvine  or  brandy.  To  procure  sleep, 
Krafft-Ebing  recommends  in  young  strong  people,  chloral  hydrate, 
gr.  15-30,  with  or  without  gr.  f  of  morphia,  every  three  or  four 
hours  for  tAvo  or  three  doses;  if  this  plan  fails  give  ext.  opii 
gr.  i  eA'ery  three  or  four  hoiurs  till  the  desired  effect  is  obtained ; 
he  recommends  the  drug  to  be  used  hypodermically  (1  in  20), 
but  if  this  cannot  be  managed,  it  may  be  administered  in  a  clyster 
or  suppository  ;  it  should  be  continued  in  small  doses  {\-^  gr.) 
for  a  few  days  after  the  critical  sleep.  In  complicating  and 
pyretic  cases  give  opium  with  abundance  of  Avine  or  spirit;  or 
methylal  (AA^hich  is  not  a  cardiac  depressant)  TT1.H  eA^ery  tAvo  or 
three  hours  subcutaneously  (1  in  10)  ad  effectum  (after  fourth 
or  fifth  injection  as  a  rule) ;  or  paraldehyde  5iij  daih',  or  amylene 
hydrate,  oiss  daily,  until  sleep  is  induced.  "When  there  is  extreme 
exhaustion  give  5j  to  5]ss  of  zinc  acetate  daily,  Avell  diluted,  in  a 
mucilaginous  A'ehicle.  Krafft-Ebing  treats  the  alcoholic  psychoses 
on  the  same  lines,  with  the  addition  of  ergotin  or  digitalis  if 
indicated.  In  all  forms  quinine  should  be  giA'en  during  con- 
A'alescence. 

Morphinismus. — The  daily  dose  should  be  diminished  A^'ery 
gradually,  except  that  the  first  reduction  may  amount  to  a  half 
or  a  third  of  the  daily  dose.  The  strength  should  be  maintained 
by  giving  milk  and  brandy  freely.  Several  physicians  haA'e 
treated  cases  of  morphinism  and  of  alcoholism  successfully  Avith 
hypnotic  suggestion.  If  the  patient  continues  to  take  morphine 
clandestinely  after  his  suj)posed  cure,  an  examination  of  the  urine 
wall  rcA'eal  the  fact. 

Cocaiiiisin  (Chronic). — Clouston  recommends  amm.  bromid., 
brandy  or  Avine,  tea  and  coffee  ;  possibly  paraldehyde  or  sul- 
phonal  for  two  or  three  nights. 

For  a  list  of  the  mental  diseases  capable  of  being  cured  or 
ameliorated  by  the  treatment  of  the  underlying  bodily  disorders  or 
functional  over-action,  see  above  (Section  A.,  Home  Treatment). 


LEGAL    REGULATIONS    AND   FORENSIC   PSYCHIATRY.  269 


CHAPTER    IX. 

LEGAL  KEGULATIONS  AND  FOKENSIC  PSYCHIATRY. 

Certification  of  Insane  Private  Patients  in  England  and 
Wales — Voluntary  Boarders — Laws  as  to  Keeping  Single 
Patients  in  England  and  Wales — Chancery  Patients — 
Uncertified  Lunatics — Pauper  Lunatics — Lunatics  (not 
Paupers)  not  under  proper  Care  and  Control  or  Cruelly 
Treated  or  Neglected — Wandering  Lunatics — Criminal 
Lunatics — Certification  of  the  Insane  in  Scotland- 
Certification  OF  THE  Insane  in  Ireland — Certification  of 
the  Insane  in  the  State  of  New  York — Certification  of 
THE  Insane  in  the  States  of  Connecticut,  Pennsylvania, 
Massachusetts,  and  Illinois — Testajnientary  Capacity  of 
the  Insane — Evidence  (Testimony)  of  the  Insane — Legal 
Tests  of  Insanity  and  Legal  Responsibility  of  the  Insane. 

CERTIFICATION  OF  INSANE  PRIVATE  PATIENTS 
IN  ENGLAND  AND  WALES. 

It  having  been  decided  that  the  patient  is  to  enter  a  lunatic 
hospital,  a  licensed  or  unlicensed  house,  or  a  county  asylum 
(as  a  private  patient)  and  one  having  been  selected,  the  first  step 
is  to  write  to  the  proprietor  or  medical  superintendent  for  the 
requisite  statutory  forms.  These  consist  of  a  form  of  "  L^rgency 
Order,"  one  of  "  Petition  for  an  Order  for  reception  of  a  Private 
Patient,"  two  of  "Statement  of  Pai-tieulars,"  one  annexed  to 
the  Petition,  and  one  to  the  Urgency  Order,  three  of  "  Certificate 
of  Medical  Practitioner,"  one  of  which  should  have  a  space  for 
the  Urgency  Certificate  below  the  space  for  "Facts  communi- 
cated by  others."  The  Medical  Certificates  must  now  be  on 
separate  sheets  of  paper,  and,  though  essentially  the  same  as 
formerly,  are  som.ewhat  diff'erently  worded  since  the  passing 
of  the  Lunacy  Act,  1890. 

When  the  patient  is  violent,  homicidal,  or  suicidal,  refuses 
food,  is  restless,  sleepless,  and  noisy  at  night,  or  is  greatly  excited 
and  very  restless  and  noisy  in  the  daytime,  he  can  be  removed, 
if  fit  physically  for  removal,  on  the  "Urgency  Order,"  accom- 
panied by  one  Medical  Certificate  containing  a  statement  or 
Certificate  of  Urgency  added  below  the  "  Facts  communicated  by 
others." 


270  LEGJAL   REGULATIONS   AND    FORENSIC   PSYCHIATRY. 


53  Vict.  c.  5,  Sched.  2,  Form  4. 

FORM    OF   UEGEXCY   ORDER   FOR   THE    RECEPTION   OF 
A  PRIVATE   PATIENT. 


(a)  0?- hospital, 
asylum,  or  as  a 
single  patient. 


(b)  Name  of 
patient. 


(c)  Lunatic,  or 
an  idiot  or  a 


I,  the  undersigned,  being  a  person  twentj'-one  years  of 
age,  hereby  authorise  you  to  receive  as  a  Patient  into 

your  house  (a) 

ib] . 

as  a  (c) - 


peison  of  unsound    whom  I  last  saw  at 
mind. 


{d)  Someday 
within  two  days 
before  the  dats 
of  the  order. 


(e)  Husband, 
wjfe,  father, 
father-in-law, 
mother  mother-in- 
law,  son,  son-in- 
law,  daughter, 
daughter-in-law, 
brother, 
brother-in-law, 
sister,  sister-in- 
law,  partner, 
or  assistant. 
*[Ifnottlie 
husband  or  wife, 
or  a  relative  of 
the  patient,  the 
person  signing 
to  state  as  briefly 
as  possible  : — i. 
Why  theorde' 
is  not  signed  by 
the  husband  or 
wife,  or  a  rela- 
tive of  ihe 
patient.    2.  His 
or  her  connec- 
tion with  the 
patient,  and  the 
circumstances 
under  which  he 
or  she  signs.] 
(/)  Superinten- 
dent of the 

asylum, 

hospital,  or  resi- 
dent licensee  of 

the house 

[describing  the 
asylum,  hos- 
pital, or  house 
by  situation  and 
name] 


on  the  (d) day  of _^189     . 

I  am  not  related  to  or  connected  with  the  Person 
signing  the  Certificate  which  accompanies  this  Order 
in  any  of  the  ways  mentioned  in  the  margin. (e)  Sub- 
joined [or  annexed]  hereto  is  a  Statement  of  Particulars 
relatmg  to  the  said 

(Signed) 


Name  and  Christian 
Name  at  length 

Eank,  Profession,  or 
Occ^opation  {if  any) 

Full  Postal  Address  - 

*Hoiu  related  to  or 
connected  with  the 
Patient  -        -        - 


Dated  this_ 
To  if) 


day  of_ 


189 


LECIAL   REGULATIONS   AND   FORENSIC    PSYCHIATRY.  271 

Form  2. 

STATEMENT  OF  PARTICULARS  REFERRED  TO  IN  THE 
ABOVE  (OR  ANNEXED)  ORDER. 

If  any  Particulars  are  not  hnoivn,  the  Fact  is  to  he  so  stated. 

[Where  the  patient  is  in  the  petition  or  order  describe!  as  an  idiot,  omit  the 
particulars  marked*.] 


The    following    is    a    Statement    of    Particulars    relating    to  the 
said 

Name  of  Patient,  with  Christian 

Name  at  length 
Sex  and  Age        .         .         .         . 
*Married,  Siaigie,  or  Widowed     - 
*Rank,   Profession,   or   previous  } 

Occupation  (if  any)  -         -  \ 

*Religious  Persuasion 
Residence    at     or     immediately  ( 

previous  to  the  date  hereof      -  \ 
*  Whether  First  Attack 
Age  on  First  Attack    - 
When     and     where     previously  \ 

under    Care    and     Treatment  I 

as  a  Lunatic,  Idiot,  or  Person  t 

of  Unsound  Mind     -         -         -  i 
*Duration  of  existing  Attack 
Supposed  Cause  -        -         -        - 
Whether  subject  to  Epilepsy 
Whether  Suicidal 
W^hether  Dangerous   to    Others, 

and  in  what  way 
Whether  iiny  near  Relative  has 

been  afflicted  with  Insanity     -  ( 
Names,    Christian   Names,    and 

full   Postal    Addresses  of    one 

or    more     Relatives     of     the 

Patient    .        -        -         -        - 
Name  of   the   Person  to   whom 

Notice  of   Death  to    be  sent, 

and   full    Postal    Address,     if 

not  already  given     - 
Name  and  Postal  Address  of  the  ) 

usual    Medical    Attendant    of  ' 


the  Patient 


n 


(Signed)  ig) 

(g)   Wlien  the  peli-  i  Name,  loith    Christian 

tioner  or  person  sign-  NnmP  nf  Jpvnfh 

mg  an  urgency  order  \        j-i u-nvK,  uu   vmiyijiu 


s'not  the  person  who          \  Rank,     Profession,     or 

7d7   te    'folloZTnl]         -!  Occzcpation  (if  any)  - 

particulars     concern-  How  Related  to  or  other- 

^Jns^^ei^Zen^""  ^cisc  Connected   with 

\  the  Fat  tent 


172 


LEGAL    llEGULATIONS    AND    FORENSIC    PSYCHLITRY. 


53  Vict.  c.  5.— Sched.  2,  Form  8. 
CERTIFICATE     OF    MEDICAL    PEACTITIOXER. 


(a)  Insert  resi- 
dence of  patient, 

(6)  County  City, 
or  Borough,  as  the 
case  may  be 

(c)  Insert  profes- 
sion or  occupation, 
if  any. 

Uh  Insert  the 
place  of  examina- 
tion, frivin?  the 
name  of  the  street, 
with  number  or 
name  of  house,  or 
should  there  bs 
no  number,  the 
christian  and  sur- 
name of  occupier. 

iei  County,  city, 
or  borough,  as  the 
case  may  be. 

If)  Omit  this 
where  only  one 
certificate  is  re- 
quired. 

(g)  A  lunatic,  an 
idiot,  or  &  person 
of  unsound  mind. 

(h)  If  the  same 
or  other  facts  were 
observed  previous 
to  the  time  of  the 
examination,  the 
certifier  is  at  liber- 
ty to  subjoin  them 
in  a  separate  para- 
graph. 

(i)  The  names  & 
christian  names  ( if 
known)  of  inform- 
ants to  be  given, 
with  their  address- 
es &  desci'iptions. 

*  Or,  not  to  be. 

Ck)  Strike  out 
this  clause  in  case 
of  a  patient  whose 
removal  is  not  pro- 
posed. 

(l)  Insert  full 
postal  address. 


of  (a)_ 


in  the  (7j)_ 


In  the  matter  of 

of (c) an  alleged  lunatic. 

I,  the  rmdersigned do  hereby  certify  as  follows  : 

1.  I  am  a  person  registered  under  the  Medical  Act, 
1858,  and  I  am  in  the  actual  practice  of  the  medical  pro- 
fession. 

2.  On  the day  of      189       at  (d) 

in  the    (e) of 'separately  from  any  other 

practitioner)  (/)  I  personally  examined  the  said 

and  came  to  the  conclusion  that      he  is  (g) and  a 

proper  person  to  be  taken  charge  of  and  detained  under 
care  and  treatment. 

3.  I  formed  this  conclusion  on  the  following  grounds, 
■siz. : — 

(a.)  Facts  indicating  Insanitj' observed  bj^  myself  at  the 
time  of  examination  (h),  viz. 

(6.)  Facts  communicated  by  others  (i),  viz. 

If  an  Urgency  Certificate  is  required  it  must  be  added 
here  {See  Form  9). 

4.  The  said appeared  to  me  to  be* in 

a   fit  condition  of  bodily  health  to  be   removed   to   an 
asylum,  hospital,  or  licensed  house  (k). 

5.  I  give  this  certificate  having  first  read  the  section 
of  the  Act  of  Parliament  printed  below. 

(Signed) 

of  (Z)^ 

Dated  this day  of 189 


LUNACY  8. 


(53  Vict.  c.  5, 
SS.  4,  11,  16,  28,  29.) 


'^Extract  from  section  317  of  the  Lunacy  Act,  1890. 

Any  person  who  makes  a  wilful  misstatement  of  any 
material  fact  in  any  medical  or  other  certificate,  or  in 
any  statement  or  report  of  bodily  or  mental  condition 
under  this  Act,  shall  be  guilty  of  a  misdemeanour. 


LE«AL    REGULATIONS   AND    FORENSIC    PSYCHIATRY.         273 

53  Vict.  c.  5.— Form  9. 
STATEMENT    ACCOMPANYING     UEGENCY     ORDER. 


I  certify  that  it  is  expedient  for  the  welfare  of  the  said 
[en-  for  the  public  safety,  as  the  case  may  be}  that 


the  said should  be  forthwith  placed  under  care 

and  treatment. 

My  reasons  for  this  conclusion  are  as  follows  : 


The  medical  practitioner  who  signs  the  certificate  accompanying 
an  Urgency  Order  should  have  examined  the  patient  not  more 
than  two  clear  days  prior  to  the  patient's  admission  to  an 
asylum,  lunatic  hospital,  licensed  house,  or  as  a  single  patient, — 
for  fiu'ther  instructions  read  the  marginal  notes  of  the  certificate. 
As  to  persons  capable  legally  of  signing  "  Urgency  Order,"  see 
marginal  notes  of  form.  It  does  not  matter  whether  the 
"Urgency  Order,"  or  the  medical  certificate  accompanying  it,  is 
signed  first,  but  both  must  be  signed  within  two  days  of  the 
patient's  admission  to  the  asylum,  etc.  The  Urgency  Order 
remains  in  force  seven  days,  or  until  the  pending  petition  is 
finally  disposed  of. 

In  any  case,  whether  the  patient  is  removed  forthwith  on  an 
urgency  order,  or  whether  it  is  not  considered  necessary 
to  do  so,  a  "Petition  for  an  Order  for  reception  of  a  Private 
Patient,"  must  be  sent  to  a  County  Court  Judge,  a  Stipen- 
diary Magistrate,  or  one  of  the  Justices  appointed  annually 
at  quarter  sessions  to  hear  such  petitions.  There  is  a  list,  com- 
piled by  Sutherland,  published  at  a  small  price,  of  the  specially 
appointed  J.P.'s  who  are  entitled  to  make  orders  for  the  reception 
of  pi"ivate  patients.  But  the  recently  passed  Lunacy  Act,  1891 
(54  and  55  Vict.  c.  65)  is  calculated  to  diminish  the  inconveniences 
hitherto  experienced  in  having  orders  signed.  By  Sect.  2-1  of 
this  new  x\ct,  the  judicial  authority  is  empowered  to  act  when 
he  has  not  jurisdiction  in  the  place  where  the  alleged  lunatic  is  ; 
he  can  also  transfer  a  petition  to  another  judicial  authority  who 
is  willing  to  receive  it.  If  a  Justice  has  not  been  specially 
appointed,  an  order  signed  by  him  will  be  valid  if  approved  by  a 
judicial  authority  within  fourteen  days.  It  is  also  practically 
provided  that  the  justices  of  a  county  or  borough  may  specially 
appoint  all  the  justices  thereof  to  sign  orders  for  the  reception 
of  private  patients.  The  jurisdiction  of  any  judicial  authority 
is  to  continue  until  a  fresh  appointment  is  made.  The  Lord 
Chancellor  may  empower  the  chairman  of  a  board  of  guardians 
to    sign    orders    for    the    reception    of   pauper    lunatics.      The 

18 


274         LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

petition  should,  if  possible,  be  presented  by  the  husband  or  wife 
of  the  alleged  lunatic,  and  if  not,  the  reasons  why  it  is  not 
must  be  stated,  as  well  as  the  circumstances  under  which  the 
petition  is  presented  by  the  petitioner.  The  judicial  authority 
must  make  an  order  forth ■s\TLth  or  appoint  a  time,  within  seven 
days,  for  the  consideration  of  the  petition.  He  may  then  either 
make  an  order,  dismiss  the  petition,  or  adjourn  its  consideration 
for  any  period  not  exceeding  fourteen  days  for  further  evidence 
or  information.  For  further  particulars  see  form  and  read 
marginal  notes. 

53  Vict.  c.  5— Sched.  2,  Form  1. 

PETITION    FOB.    AN     ORDER    FOR    RECEPTION     OF     A 
PRIVATE     PATIENT. 


(a) -a  justice  of  IN  THE  MATTER  OF a  person  alleged  to  be  of 

the   peace  for  — ,  ^                      ° 

or  his  houour  the  unsound  mind, 
judge  of  the  coun- 

stipencliary  niagis-        To  (a) The  Petition  of of  (b) in 


the  County  of 


trate  f or 

(b)  Full  postal 
address,  and  rank,         _,       ^  ,  ^  . 

profession,  or  oc-        1.     I  am (c)  years  of  age. 

cupation. 

(f)  At  least  twen-        2.     I  desire  to  obtain  an  Order  for  the  Reception  of 

, ,,  ,"  ,       ,.  as  (d)  in  the  (e) of situate 

(d)  A  lunatic,  or    ^    '  -  *■  ' 

an  idiot,  or  person    g^^  (  f\ 

of  unsound  mind  ^^  ' 

(e)  Asylum,   0)-        :3_     I  last  saw  the  said     at on  the  (ff) 

hcspital,  Of  house, ^•" 

as  the  case  may  be.  day  of  189      . 

(/)  Insert  a  full 

description   of   the         4       j  ^^  ^^^^   n^\ ^f  ^^ie  said [or  if  the 

name  and   locality  ^   ' '-        •' 

0/  *;ie  asylum,  hos-  petitioner  is  not  connected  loith  or  related  to  the  patient, 

house,  or  the  full  g^ate  as  follotvs:']    I  am  not  related  to  or  connected  with 

name,  address,  and  "               J                -i 

description   of  the  ^^^  ^^^^ 

person     who    is   to  — ■ 

tal;e  charge  of  the 

iKitient  as  a  single  The  reasons  why  this  Petition  is  not  presented  by  a 

patient. 

[g)  Someday         relation  or  connection  are  as  follows: 

within  14  days  be- 
fore the  date  of  the        The  circumstances  under  which  this  Petition  is  pre- 
presentation  of  the 

petition.  sented  by  me  are  as  follows  : 

li.)  Here  state  the  -,      ■,^      ■.^  r  ii 

connection  or  rela-       5.     I  am  not  related  to  or  connected  with  either  01  the 
tionsliip    with    the  .       .  i  ■   n  ,  1  ■ 

vatitnt.  persons  signing  the  certincates  which   accompany  this 

petition  as  [where  the  petitioner  is  a  man)  husband,  father, 

father-in-law,   son,    son-in-law,  brother,   brother-in-law, 

partner,  or  assistant  (or  ivhere  the  petitioner  is  a  woman), 

wife,  mother,  mother-in-law,  daughter,  daughter-in-law, 

sister,  sister-in-law,  partner,  or  assistant. 


LEGAL    REGULATIONS   AND    FORENSIC    PSYCHIATRY.         275 

6.  I  undertake  to  visit  the  said personally  or 

by  some  one  specially  appointed  by  me  at  least  once  in 
every  six  months  while  under  care  and  treatment  under 
the  Order  to  be  made  on  this  Petition. 

7.  A   Statement  of   Particulars  relating  to  the   said 
accompanies  this  Petition.    If  it  is  the  fact,  add: 


The  said has  been  received  in  the 


Asylum,  or  Hospital,  or  House,  as  the  case  may  be,  under 
an  Urgency  Order  dated  the 

The  petitioner  therefore  prays  that  an  Order  may  be 
made  in  accordance  with  the  foregoing  Statement. 


(0  Full  christian  Signed  (l) 

and  surname. 


Dated  this day  of 189 


When  neither  certificate  is  signed  by  the  usual  medical  attend- 
ant the  reason  must  be  stated  by  the  petitioner  (see  Form  below). 

WHEN    NEITHER     CERTIFICATE     IS     SIGNED     BY     THE 
USUAL    MEDICAL     ATTENDANT. 


53  Vict.,  c.  5,  s.  31.      J^  the  undersigned,  hereby  state  that  it  is  not  practicable 

to  obtain  a  Certificate  from  the  usual  Medical  Attendant 

tiint.^''™^  °^  ^'''   of  (a) for  the  following  reason,  viz. : 

(6)  To  be  signed                           <^in-icrl  lh\ 
by  the  petitioner.  bigaea  (0) 

189     , 


If  a  previous  petition  has  at  any  time  been  dismissed,  the  facts 
relating  to  its  dismissal  are  to  be  stated  in  the  fresh  petition  (see 
Form  below). 

WHEN     A    PREVIOUS     PETITION     HAS     BEEN    DISMISSED. 


53  Vict.  c.  5,  s.  7(4).  J^  the  undersigned,  hereby  state  that  a  former  Petition 

(o)  Name  of  pa-  r       ,\.  ,•  i  ,    s  •    j.      /■L^ 

tient.  ioT  the  reception  of  (a) into  (o) was  pre- 

(fc)  Name  of  asy-  ,    j  ,  ,   ,  •      .i  .i       ^  -,nr^ 

lum,  hospital,    li-  sented  to (c) in  the  month  of 189 

censed   house,    or  ,   ,.        .        , 

single  charge.  and  dismissed, 


276         LEGAL  REGULATIONS   AND    FORENSIC    PSYCHIATRY. 

(c)  Justics  of  the  Herewith  is  a  copy  (furnished  by  the  Commissioners  in 

peace  for  ,  or  x  ^    v                         j 

juage   of   county  Lunacy)  of  the  Statement  sent  to  them  of  the  reasons  for 

court  of  — ,  or  sti-  *'  ' 

pendiary      magis-  its  dismissal, 
trate  for  — . 


(Signed) 


189 


NOTE. — This  Copy  is  to  be  obtained  from  the  Commis- 
sioners in  Lunacy  by  the  Petitioner  at  his  oicn  expense. 


[An  Order  for  Reception  of  a  Private  Patient  is  to  be 
obtained  upon  a  private  application  by  Petition  to  a  Judge 
of  County  Courts,  or  Stipendiary  Magistrate,  or  Metro- 
politan Police  Magistrate,  or  specially  appointed  Justice 
of  the  Peace.  {Vide  supra  as  to  operation  of  Lunacy  Act, 
1891).  The  Petition  is  to  be  presented,  if  possible, 
by  the  husband  or  wife,  or  by  a  relative  (i,e.,  a  lineal  an- 
cestor or  a  lineal  descendant,  or  lineal  descendant  of  an 
ancestor  not  more  remote  than  great  grandfather  or  great 
grandmother)  of  the  Lunatic,  and  is  to  be  accoinpanicd 
by  a  Statement  of  Particulars  and  two  Medical  Certifi- 
cates on  separate  sheets  of  paper.  One  of  the  Medical 
Certificates  accompanying  the  Petition  must,  if  practic- 
able, be  by  the  usual  Medical  Attendant  of  the  Lunatic  ; 
if  not  by  him  the  reason  must  be  stated  (see  Form  above). 
If  a  previous  Petition  has  at  any  time  been  dismissed,  the 
facts  relating  to  its  dismissal  are  to  be  stated  in  the  fresh 
Petition  (see  Form  above) ;  and  the  Petitioner  must  ob- 
tain from  the  Commissioners  in  Lunacy  a  copy  of  the 
statement  sent  to  them  of  the  reasons  for  its  dismissal, 
and  present  this  copy  with  his  Petition.  The  Reception 
Order  (which  will  not  remain  in  force  for  more  than  seven 
days  after  its  date),  the  Petition,  the  Statement  of  Par- 
ticulars, and  the  ]\Iedical  Certificates  must  be  sent  to  the 
Superintendent  or  Proprietor  of  the  Asylum,  Hospital,  or 
House  where  the  patient  is  to  be  received.] 


53  Vict.  c.  5 — Sched.  2,  Form  3. 

ORDER  FOR  RECEPTION  OF  A  PRIVilTE  PATIENT  TO  BE 
MADE  BY  A  JUSTICE  APPOINTED  UNDER  THE  LUNACY 
ACT,  1890  (see  above  as  to  effect  of  Sict.  24  of  Lunacy  Act,  1891), 
JUDGE  OF  COUNTY  COURT  OR  STIPENDIARY^  MAGISTRATE, 


— -^  speSallT'ap^  T,   tbe   undersigned, ^being    (a) upon    the 

Lrmacy  Tot"i89o^,  petition  of of  (b) in  the  Matter  of 

county  court°of  —,  a  Lunatic  (c)_ accompanied  by  the  Medical  Cer^ 

ma^istrate^for'— .'^  tificates  of and hereto  annexed,  and  wpon 


LEGAL  REGULATIONS    AND    FORENSIC   PSYCHIATRY.         277 

iht  Address  and  the  undertakintf  of  the  said  Id)                to  visit  the  said 

occupation.  °  ^     

(c)  Or  an  idiot  or personally  or  by  some  one  specially  appointed  by 

mTnT  °^  '"'^°''°^    the  .said  (d) once  at  least  in  every  six  months 

(rf)  Nameofpetl-  #hile  under  care  and  treatment  under  this  Order,  hereby 
tioner. 

(e)  Asylum    or    authorise  you  to  receive  the  said as  a  Patient  into 

hospital,  or  house  vnnr  ^ol 

or  as  a  single  pa-    J"'^'-  \^) 

*^®"  And  I  declare  that  I  have  [or  have  not]  personally  seen 

the  said before  making  this  Order. 

(/,  To    be  ad-        Dated  this day  of 189     . 

cii-essed      to      the  ■'       ■ 

i^Stof^Kyl  {Signed)  (a)_ , 

lum  or  hospital,  or  ^  Justice  for appointed  under  the  above-men- 

to     the     resident  Honed  Act  [or  the  Judge  of  the  County  Coxtrt  of 

licensee     ot      tne  or  a  Stipendiary  Maaistrate]. 

house  m  which  the  •"             »       j            j 

patient    is    to   be  To   ( f) 

placed.  ^•'  ' 


A  member  of  the  managing  committee  of  a  lunatic  hospital 
must  not  sign  reception  orders  or  certificates. 

An  order  on  petition  must  l)e  acted  upon  within  seven  clear  days 
after  its  date,  but  "summary  reception  orders  "  may  be  suspended. 
(See  "Lunatics  not  under  proper  Care,"  etc.,  and  "Wandering 
Lunatics,"  postea). 

The  petition  should  be  accompanied  by  a  "  Statement  of 
Particulars  "  similar  to  that  accompanying  the  urgency  order,  and 
by  two  medical  certificates  (on  separate  sheets  of  paper)  one  of 
which  should,  if  possible,  be  under  the  hand  of  the  patient's 
regular  medical  attendant.  The  statement  of  particulars  may  or 
may  not  be  made  by  the  j^erson  presenting  the  petition,  or  in  the 
case  of  the  urgency  order  by  the  person  making  the  order,  but  it 
(the  statement  of  particulars)  must  be  signed  by  the  person 
making  it.  When  this  person  is  not  he  who  signed  the  petition 
or  urgency  order,  certain  particulars  must  be  added,  viz.,  the 
address,  etc.  of  the  person  signing  (see  Form  ante). 

The  medical  men  must  have  personally  examined  the  patient 
separately  not  more  than  seven  days  before  the  petition  is  pre- 
sented, and  the  "Facts  indicating  insanity"  must  be  those 
observed  at  the  time  of  examination,  though  after  sufficient  facts 
have  been  stated  to  proA'e  insanity,  other  facts  observed  at  ])re- 
ceding  or  subsequent  dates  may  be  added  (see  Form  above).  The 
facts  should  be  clear  and  explicit ;  delusions  should  be  sought  for, 
given,  and  stated  to  be  delusions  ;  hallucinations  (of  which  sense 
or  senses  and  in  what  form) ;  morbidly  defective  memory  (facts 
illustrating  this  defect) ;  abnormal  loquacity ;  incoherence 
(examples  of  such  incoherence) ;  noisiness ;  destructiveness ;  ob- 
jectionable habits;  violence    (in  what  way  violent) ;  attempts  to 


278  LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

commit  suicide  (by  what  means) ;  homicidal  attempts  (in  what 
way  and  upon  whom) ;  emotional  exaltation ;  emotional  depression ; 
sleeplessness ;  restlessness  and  motor  excitement ;  refusal  of  food, 
fluid  or  solid.  The  practitioner  who  makes  and  signs  the  urgency 
certificate  can  make  and  sign  one  of  the  other  two  certificates  and 
found  both  his  documents  on  the  same  examination  of  the 
patient,  and  it  is  not  necessary  that  the  wording  should  differ. 

In  the  medical  certificates,  names,  dates,  and  addresses,  should 
be  carefully  and  fully  entered,  and  attention  should  be  given  to 
the  marginal  notes  indicated  by  the  small  letters  or  numbers  in 
the  body  of  the  certificate.  If  a  certificate  cannot  be  obtained 
from  the  usual  medical  attendant,  the  fact  must  be  stated  in 
writing  by  the  petitioner  to  the  judge  or  magistrate,  such 
statement  to  form  part  of  the  petition  (see  Form  above). 

The  following  persons  are  disqualified  from  signing  medical 
certificates,  either  urgency  or  other : — The  petitioner  or  person 
signing  the  urgency  order,  the  husband  or  wife,  father  or  father- 
in-law,  mother  or  mother-in-law,  son  or  son-in-law,  daughter  or 
daughter-in-law,  brother  or  brother-in-law,  partner  or  assistant  of 
the  petitioner  or  person  (signing  the  urgency  order). 

Neither  of  the  persons  signing  the  medical  certificates  for  the 
reception  of  a  patient  shall  be  father  or  father-in-law,  mother  or 
mother-in-law,  son  or  son-in-law,  daughter  or  daughter-in-law, 
brother  or  brother-in-law,  sister  or  sister-in-laAv,  or  the  partner  or 
assistant  of  the  other  of  them  (see  under  heading  "Single 
Patients,"  postea).  Medical  visitors  are  not  to  sign  for  reception 
into  a  licensed  house  or  hospital  unless  directed  to  visit  the 
patient  by  a  judicial  authority,  etc. 

According  to  Section  330  of  the  Lunacy  Act,  1890,  a  person 
who  has  before  the  passing  of  this  Act,  signed  or  carried  out  an 
order  or  a  medical  certificate  that  a  person  is  of  unsound  mind,  or 
Avho  presents  a  petition  after  the  passing  of  the  Act,  or  does 
anything  in  pursuance  of  this  Act  shall  not  be  liable  to  any  civil 
or  criminal  proceedings  if  such  person  has  acted  in  good  faith, 
and  with  reasonable  care.  If  any  proceedings  should  be  taken, 
they  can  be  stayed  by  a  summary  application  to  the  High  Court 
or  a  Judge  thereof,  upon  such  terms  as  to  costs,  etc.,  as  the  Court 
or  Judge  may  think  fit,  "if  the  Court  or  Judge  is  satisfied  that 
there  is  no  reasonable  ground  for  alleging  want  of  good  faith 
or  reasonable  care." 

No  prosecution  for  a  misdemeanour  under  Section  317,  Lunacy 
Act,  1890  (see  extract  below  Medical  Certificate  form)  can  take 
place  except  by  order  of  the  Commissioners  or  by  the  direction  of 
the  Attorney-General,  or  the  Director  of  Public  Prosecutions. 

Lunacy  Act,  1890  (53  Vict.  Ch.  5),  Sect.  331.— (1,)    "An 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  279 

action  brought  by  any  person  \ylio  has  been  detained  as  a  lunatic 
against  any  person  for  anything  done  under  this  Act  shall  be 
commenced  within  twelve  months  next  after  the  release  of  the 
party  bruiging  the  action,  and  shall  be  laid  or  brought  in  the 
county  or  borough  where  the  cause  of  action  arose,  and  not  else- 
where ;  (2,)  If  the  action  is  brought  in  any  other  county  or 
borough  or  is  not  commenced  within  the  time  limited  for  l)ringing 
the  same,  judgment  shall  be  given  for  the  defendant." 

Examination  of  Patient  in  Asylum  or  of  Single  Patient. 

According  to  Section  49  of  the  Lunacy  Act,  1890,  any  person, 
whether  a  relative  or  friend  or  not  of  a  patient  who  is  detained  in 
any  asylum,  etc.,  may  apply  to  the  Commissioners  to  have  such 
patient  examined  by  two  medical  pi-actitioners,  and  if  the 
Commissioners  are  satisfied  that  it  is  proper  to  grant  such  order, 
they  may  do  so.  If,  after  two  separate  examinations  with  an 
interval  of  at  least  seven  days  between  such  examinations,  the 
two  medical  practitioners  certify  that  the  patient  may,  without 
risk  to  himself  or  injury  to  the  public,  be  discharged,  the  Com- 
missioners may  order  the  patient  to  be  discharged  at  the  expiration 
of  ten  days  from  the  date  of  the  oixler. 

VOLUXTAEY  BOAEDEKS. 

The  superintendent  or  proprietor  of  a  licensed  house  may  now, 
with  the  previous  consent  in  writing  of  two  of  the  Commissioners, 
or  where  the  house  is  licensed  by  the  justices,  of  two  of  the 
justices,  receive  and  lodge  as  a  boarder  for  the  time  specified 
in  the  consent  any  person  who  is  desirous  of  voluntarily  submitting 
to  treatment.  After  which  time  (unless  it  is  extended  by  further 
consent)  such  boarder  must  be  discharged.  Any  relative  or  friend 
of  a  patient  may  be  received  under  the  same  conditions. 

The  intending  boarder  must  himself  apply  to  the  commissioners 
or  justices  for  their  consent. 

A  boarder  may  leave  a  licensed  house  by  giving  twenty-four 
hours'  notice  to  the  superintendent  or  proprietor  of  his  intention 
to  do  so,  and  if  prevented  from  so  doing,  is  entitled  to  recover  £10 
from  the  superintendent  or  proprietor  for  each  day,  or  part  of  a 
day,  during  which  he  is  detained. 

LAWS   AS   TO   KEEPING    "SIXGLE   PATIENTS" 
IN  ENGLAND  AND  WALES. 

A  "  Single  Patient  "  is  a  person  received  for  profit  into  an  un- 
licensed house  as  a  lunatic  under  Certificates. 

Under  special  circumstances  the  Commissioners  may  allow 
more  than  one  ]oatient  to  be  received  as  Single  Patients  into  the 
same  unlicensed  house  (Section  46,  Lunacy  Act    1891).      Other- 


280         LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

wise  it  is  a  misdemeanour  to  detain  two  or  more  lunatics  in 
an  unlicensed  house. 

"Any  person  who  for  payment  takes  charge  of  or  receives 
to  board  or  lodge  any  person  as  a  lunatic  shall  be  deemed  to  be  a 
person  deri^dng  profit  from  the  charge  of  a  lunatic  within  the 
meaning  of  Lunacy  Act,  1845"  (Lunacy  Acts  Amendment  Act, 
1889,  Section  35,  "Jour.  Ment.  Sci."). 

Duties  of  Person  haiing  care  or  charge  of  Single  Patient. 

(The  paragraphs  marked  with  an  asterisk  apply  also  to  the  proprietm-s 
of  private  asyhwis  in  so  far  as  private  patients  are  concerned.) 

*(1,)  To  receive  with  the  patient  the  medical  certificate  or 
certificates,  along  with  the  urgency  order  or  petition  and  judge's 
order,  and  the  statement  of  particulars,  for  the  description  of 
which  see  the  preceding  pages.  To  receive  a  patient  without 
these  documents  is  a  misdemeanoiu*  except  where  no  profit  is 
derived  from  the  charge,  or  in  the  case  of  chancery  patients  or 
of  the  transfer  of  a  patient.  Blank  forms,  etc.,  may  be  pur- 
chased through  a  bookseller  from  Eyre  and  Spottiswoode, 
East  Harding  Street,  Fleet  Street,  E.G.,  or  from  Shaw  and  Sons, 
Fetter  Lane. 

The  following  persons  are  disqualified  from  signing  medical 
certificates  in  addition  to  those  already  mentioned  under  the 
heading  "  Certification,"  etc.,  viz. : — (a,)  The  person  taking  care  or 
charge  of  the  patient ;  (&,)  Any  person  interested  in  the  payments 
on  account  of  the  patient ;  (c,)  The  person  who  is  going  to  act  as 
"Medical  Attendant  "  of  the  patient ;  {d,)  The  husband  or  wife, 
father  or  father-in-law,  mother  or  mother-in-law,  son  or  son- 
in-law,  brother  or  brother-in-law,  daughter  or  daughter-in-law, 
or  the  partner  or  assistant  of  either  of  the  above  persons. 

It  is  a  misdemeanour  to  receive  a  patient  under  a  certificate 
signed  by  any  of  the  foregoing  disqualified  j)ersons. 

*(2,)  To  transmit  to  the  Commissioners  within  one  clear  day 
of  the  patient's  reception,  a  notice  of  admission  together  with  a 
true  and  perfect  copy  of  the  documents  on  which  the  patient  has 
been  received — neglecting  to  do  this  is  a  misdemeanour.  If  the 
Commissioners  find  any  of  the  certificates,  etc.,  incorrect  or 
defective,  they  may  send  the  copies  back  so  that  the  originals 
ma}'  be  amended  (with  the  consent  of  the  judicial  authority)  by 
the  persons  signing  them.  The  certificates,  etc.,  must  be  duly 
amended  (as  marked  on  the  copies  by  the  Commissioners)  within 
fouiteen  days  of  the  patient's  reception,  otherwise  his  discharge 
may  be  ordered  by  any  two  of  the  Commissioners.  Amendments 
should  be  initialed  by  the  person  making  them. 

*(3,)  When  the  patient  has  not  been  seen  by  the  judge  who 
signed  the  reception  order,  such  patient  should  receive  within 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  281 

twenty-four  hours  of  his  admission  a  notice  in  writing  of  his  right 
to  see  a  magistrate  or  judge  (other  than  the  judicial  authority 
who  made  the  order)  within  seven  days,  according  to  the 
following  Form  : — 

*  NOTICE  OF  EIGHT  TO  PERSONAL  INTERA^EW. 

Take  notice  that  you  have  the  right  if  you  desire  it,  to  be  taken  before 
or  visited  by  a  judge  of  county  courts,  magistrate  or  justice.  If  j'ou  desire 
to  exercise  such  right,  you  rhust  give  me  notice  thereof  by  signing  the 
enclosed  form  on  or  before  the  day  of 

Dated  (Signed),  CD., 

Proprietor  of  House. 

*  NOTICE  OF  DESIRE  TO  HAVE  A  PERSONAL  INTERVIEW. 
Address  Dated 

Idesiretobe  taken  before  or  visited  by  a  judge,  magistrate  or  justice 
Ita\g.-ng  jurisdiction  m  the  district  within  which  I  am  detained. 

--'1  (Signed), 

*  Unless  within  twenty-four  hours  after  admission  the  "  Medical  Attendant " 
signs  and  sends  to  the  Commissioners  the  following : — 

CERTIFICATE  AS  TO  PERSONAL  INTERVIEW  AFTER 
RECEPTION. 

I  certify  that  it  would  be  prejudicial  to  A.B.  to  be  taken  before  or  visited 
by  a  judge  of  county  courts,  magistrate  or  justice, 

(Signed),  CD., 

Medical  Attendant  of  the  said 

Reception  orders  now  remain  in  force  for  one  year,  then  for 
two  years,  then  for  three  years,  then  for  successive  periods  of 
five  years  under  certain  conditions  (see  duties  of  "  Medical 
Attendant"  jposfea). 

(4,)  To  cause  the  patient  to  be  visited  at  least  fortnightly  by  a 
medical  practitioner  who  has  not  made  either  of  the  certificates, 
and  who  derives  no  profit  from  the  charge,  and  who  is  styled  the 
"  Medical  Attendant "  of  the  patient.  Failure  to  comply  with 
this  regulation  is  a  misdemeanour  unless  the  Commissioners  have 
given  permission  for  the  visits  to  be  paid  less  frequently. 

A  medical  attendant  must  be  appointed  even  if  the  person  in 
charge  of  the  patient  is  a  medical  practitioner. 

(5,)  To  make  (if  a  medical  practitioner)  entries  in  the  Medical 
Visitation  Book  or  Medical  Journal  at  least  once  in  two  weeks, 
when  the  fortnightly  visits  of  the  medical  attendant  have  been 
permitted  by  the  Commissioners  to  be  made  less  frequently. 

*  (In  private  asylums  these  entries  must  be  made  weekly.) 


282  LEGAL   REGULATIONS   AND   FORENSIO   PSYCHIATRY. 


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LEGAL    REGULATIONS   AND    FORENSIC    PSYCHIATRY.         283 

'^'{Q,)  The  medical  visitation  book,  petition,  orders  and  cer- 
tificates must  be  so  kept  that  they  may  be  accessible  to  the 
commissioners  whenever  they  may  visit  the  patient. 

*  The  making  of  an  untrue  entry  in  the  Medical  Journal  is  a 
misdemeanour.  Upon  every  visit  of  a  Commissioner  or  Visitor 
the  medical  journal  must  be  produced. 

*(7,)  To  send  to  the  Commissioners  at  the  expiration  of  a 
month  after  the  reception  of  the  patient  a  report  as  to  the  mental 
and  bodily  condition  of  the  patient  in  such  form  as  they  may  direct. 
He  must  also  report  to  the  Commissioners  at  any  time,  when 
required. 

•''(8,)  To  send  notice  to  the  petitioner,  or  person  who  made  the 
last  payment,  as  soon  as  the  patient  recovers.  The  notice  must 
.state  that  unless  the  patient  is  removed  within  seven  days  from 
the  date  of  the  notice,  he  will  be  discharged.  If  the  patient 
is  not  so  removed  he  must  be  forthwith  discharged. 

*(8a,)  To  send  notice  of  the  discharge,  removal  or  death  of  the 
patient  to  the  Commissioners  within  two  clear  days  of  such 
discharge,  removal  or  death.  Faikure  to  send  these  notices  or 
making  a  false  statement  therein  is  a  misdemeanoiu\  "Failure  to 
send  "  entails  a  penalty  not  exceeding  £50  in  the  case  of  a  single 
patient. 

*FORM  OF  NOTICE  OF  DISCHARGE. 
I  hereby  give  you  notice  that  ,  a  private  patieni , 

received  into  this  house  on  the  day  of  189     ,  was 

discharged  therefrom  (a)  by  the  Authority  of 

on  the  dav  of  189     . 

(Signed), 

Proprietor  (or  Superintendent)  of  House. 

Dated  this  day  of  189     . 

To  the  Commissioners  in  Lunacy. 

(a)  Recovered,  or  reheved,  or  not  improved. 

-"(9,)  To  transmit  within  forty-eight  hours  of  the  death  of  the 
patient  a  duly  certified  copy  of  the  medical  attendant's  statement 
of  the  cause  of  death,  etc.,  to  the  Commissioners,  to  the  person 
who  signed  or  obtained  the  reception  order,  to  the  registrar 
of  deaths  for  the  district,  and  (within  two  days)  to  the  county  or 
borough  coroner.  Failure  to  do  so  entails  a  penalty  not  exceed- 
ing £50  in  the  case  of  a  single  patient,  and  is  a  misdemeanour  in 
all  cases. 

''■(10,)  To  give  eiFect  to  the  Commissioners'  order  within  seven 
days  of  the  visit  of  two  of  them  (one  legal,  the  other  medical) 
for  the  discharge  of  the  patient. 

(11,)  To  give  eff"ect  to  any  direction  given  by  any  two  of  the 
Commissioners  that  the  medical  attendant  of  a  single  patient  shall 
cease  to  act  in  that  capacity,  and  that  some  other  person   be 


284         LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

employed  in  his  place.      Failure  to  give  effect  to  this  direction  is 
a  misdemeanour. 

*(12,)  To  show  any  Commissioner  at  his  request  any  part  of 
the  house  or  grounds.     Eefusal  to  do  so  is  a  misdemeanour. 

One  or  more  of  the  Commissioners  once  at  least  in  every  year 
must  visit  ever^'  unlicensed  house  in  which  a  single  patient  is 
detained,  unless  such  patient  be  so  received  by  a  person  deri\"ing 
no  profit  from  the  charge,  or  by  a  committee  appointed  by  the 
Lord  Chancellor,  and  report  to  the  Commissioners  on  the 
treatment  and  state  of  bodily  and  mental  health  of  the  patient. 

A  Commissioner  or  one  or  more  Visitors  of  the  county  or 
borough  may,  at  all  reasonable  times,  on  the  request  of  the 
Commissioners,  "visit  a  single  patient  and  report  to  the  Lord 
Chancellor  or  the  Commissioners  on  the  patient's  treatment, 
health,  and  payments.  The  maximum  penalty  for  obstructing  a 
Commissioner  or  Chancery  visitor  is  £50. 

*(13,)  To  forward  unopened  all  letters  ^n^itten  by  the  patient 
and  addressed  to  the  Lord  Chancellor,  or  to  any  Judge  in  Lunacy, 
or  to  a  Secretary  of  State,  or  to  the  Commissioners  or  any 
Commissioner,  or  to  the  person  who  signed  the  order  for  the  re- 
ception of  the  patient,  or  on  Avhose  application  or  petition  such 
order  was  made.  Letters  addressed  to  other  j)ersons  than  those 
mentioned  may  be  forwarded  or  detained  at  the  discretion  of  the 
person  who  has  charge  of  the  patient,  but  if  detained,  must  be 
endorsed  by  such  person  with  the  reasons  for  detention  and  laid 
before  the  Commissioner  or  Commissioners  at  his  or  their  next 
visit.     Neglect  entails  a  penalty  not  exceeding  £20. 

''■(14,)  If  the  patient  escape,  to  transmit  to  the  Commissionei"s 
■wathin  two  clear  days  a  written  notice  of  the  escape,  and  on  his 
recapture,  a  \^Titten  notice  of  the  same  also  "wnthin  two  clear 
days.     Penalty  for  omission,  a  sum  not  exceeding  £10. 

If  the  patient  be  not  retaken  within  fourteen  days  after  his 
escape  he  can  only  be  brought  back  after  being  re-certified  and 
a  fresh  order,  etc.,  obtained.  A  patient  escaping  from  one  of  the 
three  kingdoms  (England,  Scotland,  Ireland)  to  another  of  them, 
can  now  be  retaken  on  a  warranty  granted  by  the  Lunacy 
authorities  of  the  country  from  which  he  has  escaped  after  the 
warrant  has  been  countersigned  by  any  Justice  or  Sheriff  of  the 
country  to  which  he  has  resorted. 

(L5,)  If  a  medical  practitioner,  he  must  on  the  10th  of  January, 
or  mthin  seven  days  from  that  time  in  every  year,  report  in 
■uT-iting  to  the  Commissioners  the  state  of  health,  bodily  and 
mental,  of  such  patient,  with  such  other  circumstances  as  he  may 
deem  necessary  to  be  communicated  to  the  Commissioners.  He 
must  also  furnish  a  report  when  required  at  a,ny  time  or  from 


LEGAL   REGULATIONS    AND   FORENSIC    PSYCHIATRY.  285 

time  to  time  by  the  Commissioners,  specifying  such,  particulars  as 
the  Commissioners  may  direct  ("  Archbold,"  p.  464). 

The  whole  Act  (16  and  17  Vict.  c.  98)  under  which  the 
January  report  had  to  be  made,  is  now  repealed  (53  Vict.  c.  5, 
Sched.  5).  (See  "  Duties  of  Medical  Attendant "  post,  for  reports 
now  to  be  made).  It  should,  however,  be  stated  that  the  last 
section  of  the  last-mentioned  Act  says  that  the  repeal  is  not 
to  affect  a  practice  established.  If  the  reception  order  has 
expired  through  fg-ilure  to  send  in  the  special  reports  now  re- 
quired, it  is  a  misdemeanour,  having  knowledge  of  that  fact, 
to  detain  the  patient. 

(16,)  To  comply  with  the  regulations  as  to  entries  in  the 
Medical  Visitation  Book.  Liable  to  a  penalty  not  exceeding  £5 
for  failure  to  do  so. 

(17,)  If  not  a  medical  practitioner,  he  or  she  must  keep  a  note 
of  the  days  on  which  seclusion  is  resorted  to,  and  of  the  length  of 
time  on  each  occasion,  and  must  produce  such  note  to  the  medical 
attendant  on  his  or  her  next  visit,  to  be  entered  in  the  Journal 
(Medical  Visitation  Book). 

*(18,)  According  to  Section  40  of  the  Lunacy  Act,  1890, 
mechanical  means  of  restraint  must  not  be  applied  except  for 
surgical  or  medical  treatment,  and  to  prevent  the  lunatic  from 
injui'ing  himself  or  others. 

In  every  case  a  medical  certificate  must  be  signed  describing 
the  means  used  and  the  reasons  for  it. 

CEETIPICATE  AS  TO  MECHANICAL  MEANS  OF  RESTRAINT. 

*  I,  the  undersigned  CD.  (the  Medical  Superintendent,  or  a  medical 
officer  of  the  Asylum,  or  the  Hospital,  or  the 

Medical  Proprietor  or  Attendant  of  the  House,  or  the  IMedical 

Officer  of  the  Workliouse,  or  the  Medical  Attendant  of  A.B., 

i^,  lunatic  under  care  or  treatment  at  ,  as  the  case  may  be) 

certify  that  I  have  examined  A.B.,  a  lunatic  in  the  said  (asylum,  hospital, 
house,  or  workhouse  or  the  said  A.B.,  as  the  case  may  be),  and  that  in  my 
opinion  mechanical  means  of  bodily  restraint  were  (or  are)  necessary  in 
his  case  for  purposes  of  surgical  or  (medical)  treatment  (or  to  prevent  him 
from  injuring  himself  or  others).     The  necessary  means  are  (state  themj. 

I  found  my  opinion  on  the  following  grounds  (state  them). 

(Signed) 

*  This  certificate  must  be  signed  by  the  medical  attendant  or 
by  the  medical  practitioner  having  care  and  charge  of  the  patient. 
A  full  daily  record  of  every  case  [of  mechanical  restraint]  must 
be  kept  and  a  copy,  together  Avith  copies  of  the  restraint  certifi- 
cates, sent  to  the  Commissioners  quarterly. 

Wilful  contravention  of  this  Section  is  a  misdemeanom\ 


286         LEGAL    REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

(19,)  When  he  proposes  to  change  his  residence  and  to  remove 
the  patient  ^viih  him,  he  must  give  to  the  Commissioners  and  to 
the  person  who  signed  the  order  or  petition  for  the  order  for  the 
reception  of  the  patient  seven  clear  days'  notice  of  the  proposed 
change,  with  the  exact  address  and  designation  of  the  new 
residence. 

(20,)  In  order  to  send  the  patient  to  any  specified  place  or 
places  for  the  benefit  of  his  health  for  any  definite  time  under 
proper  control,  it  is  necessary  to  obtain  the  cdnsent  of  one  of  the 
Commissioners,  and  before  such  consent  is  given  it  is  required 
that  the  approval  in  writing  of  the  person  who  signed  the 
reception  order  or  petition,  or  by  whom  the  last  payment  was 
made,  be  produced  to  such  Commissioner,  unless  he  on  cause 
being  shown  dispenses  with  the  same. 

Removal  to  a  place  not  specified  in  the  consent  is  equivalent 
to  a  discharge,  and  necessitates  readmission  by  fresh  order  and 
certificates.  If  the  patient  remains  away  longer  than  the  speci- 
fied time,  or  any  permitted  extension  of  that  time,  he  is  also 
discharged. 

*  (20,)  Applies  also  to  Metropolitan  private  asylums,  for  an 
absence  exceeding  48  hours,  but  provincial  ones  obtain  con- 
sent for  an  absence  exceeding  that  time  from  the  Visiting 
Justices. 

*  (21,)  By  obtaining  from  one  of  the  Commissioners  his  con- 
sent to  an  order  of  transfer  [made  by  the  person  who  signed  the 
petition  or  order  or  made  the  last  payment]  the  patient  can  be 
transferred  to  the  charge  of  another  person  mthout  the  necessity 
of  fresh  certificates. 

*(22,)  It  is  a  misdemeanour  for  anj-  person  having  charge  of  a 
single  patient  to  abuse,  ill-treat  or  wilfully  neglect  such  patient 
in  any  Avay  ;  such  persons  are  liable  on  conviction  on  indictment 
to  fine  or  imprisonment  or  both,  or  to  forfeit  for  every  such 
offence  on  a  summary  conviction  thereof  before  two  justices,  any 
sum  not  exceeding  £20  nor  less  than  £2. 

According  to  Archbold  (Glen's  Ed.,  1877,  page  460),  a  husband 
having  the  care  and  charge  of  his  wife,  is  not  a  person  having  the 
care  and  charge  of  a  lunatic  ^vithin  the  statute  (16  and  17  Vict. 
c.  96,  noiv  repealed),  the  proA'isions  of  which  do  not  apply  to 
persons  whose  care  or  charge  of  a  lunatic  is  of  a  purely  domestic 
nature,  or  arises  from  natural  duty  only.  But  a  person  was 
indicted  and  convicted  for  wilfully  neglecting  his  lunatic  brother. 
By  sect.  206  of  the  Lunacy  Act,  1890,  uncertified  alleged 
lunatics  may  now  be  visited  by  the  Commissioners,  (See 
"Uncertified  Patients"  2^osf-) 

"If any  person  having  the  care  or  charge  of  any  single 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  287 

patient,  or  any  attendant  of  any  single  patient,  carnally  knows  or 
attempts  to  have  carnal  knowledge  of  any  female  under    care 

or  treatment as  a  single  patient,  he  shall  be  guilty  of  a 

misdemeanour,  and,  on  conviction  on  indictment,  shall  be  liable 
to  be  imprisoned  with  or  without  hard  labour  for  any  term  not 
exceeding  two  years  ;  and  no  consent  or  alleged  consent  of  such 
female  thereto  shall  be  any  defence  to  an  indictment  or  prosecu- 
tion for  such  offence  "  (53  Vict.,  c.  5,  s.  324). 

(23,)  Should  the  person  in  charge  become  dangerously  ill,  the 
friends  of  the  patient  should  at  once  be  communicated  with, 
in  order  that  arrangements  for  a  transfer  may  be  made 
(Weatherly,  p.  102).  But  by  Sect.  59,  Lunacy  Act,  1890,  the 
Commissioners  may,  upon  the  death  of  a  person  having  charge 
of  a  single  patient,  order  the  transfer  of  the  patient  to  some 
other  person.  They  may  do  so  either  upon  the  application  of  the 
person  having  authority  to  discharge  the  patient,  or  if  he  does 
not  apply  within  seven  days  after  the  death,  upon  their  own 
motion. 

*  (24,)  The  person  who  has  charge  of  the  patient  should  not 
allow  him  to  transact  any  business.  A  person  under  certificates 
cannot  legally  transact  business. 

Upon  the  written  request  of  the  Commissioners,  or  any  two  of 
them,  single  patients  may  be  visited  by  visitors  appointed  for  the 
county  or  borough,  and  any  such  visitor  being  a  medical  prac- 
titioner is  entitled  to  remuneration.  The  Commissioners  can 
also  under  their  common  seal  specially  appoint  persons  to  visit 
urgent  cases  and  report  thereon  ;  every  such  person  has  all  the 
powers  of  a  Commissioner ;  this  may  be  done  shortly  after  the 
patient's  admission,  when  the  Commissioners  cannot  immediately 
visit  such  patient.  The  Commissioners  or  others  may  be  required 
by  the  Lord  Chancellor  or  a  Secretary  of  State  to  visit  a  lunatic 
or  alleged  lunatic,  examine,  inspect,  and  report.  Penalty  for  ob- 
structing any  person  so  authorised  other  than  a  commissioner  or 
regularly  constituted  visitor,  £20. 

Any  two  of  the  Commissioners  may  order  the  removal  of  a  patiert 
from  the  care  of  one  person  to  that  of  another,  or  to  an  asylum. 

Duties  oj  the  Medicid  Attendant. 

(The  paragraphs  marled  with  asterisks  apply  also  to  the  Medical 
Superintendents  or  Medical  Attendants  of  private  asylums.) 

The  Lunacy  Act  1845,  defines  a  "medical  attendant"  as  a 
duly  qualified  and  registered  physician,  surgeon,  or  apothecary, 
who  keeps  any  licensed  house  or  in  his  medical  capacity  attends 
any  licensed  house  or  any  asylum,  hospital,  or  other  place  where 
any  lunatic  is  confined. 

*  The  medical  attendant  of  a  single  patient  must  be  a  registered 


288         LECJAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

medical  practitioner,  not  deriving  and  not  having  a  partner, 
father,  son,  or  brother,  who  derives  any  profit  from  the  care  or 
charge  of  snch  patient, 

*  The  person  who  is  to  be  the  medical  attendant,  must  not  sign 
either  of  the  certificates  on  which  the  patient  is  received. 

*  (1,)  The  medical  attendant  must  after  two  clear  days  and 
within  seven,  from  the  date  of  reception  of  the  patient,  transmit 
to  the  Commissioners  a  report  or  statement  of  the  patient's 
mental  and  bodily  condition. 

FORM  0¥  STATEME^^T. 

I  have  this  day  (some  day  not  less  than  two,  or  more  than  seven  clear 
daj's  alter  the  admission  of  the  patient)  seen  and  esammed 

received  into  this  house  on  the         daj"  of  189     ,  and 

hereby  certify  that  with  respect  to  mental  state,  he  (or  she) 

and  that  with  respect  to  bodily  health  and  condition  he 
(or  she) 

Signed 

Medical  attendant  of 
Dated 

(2,)  The  medical  attendant  must  visit  the  patient  once,  at 
least,  in  every  two  weeks,  unless  by  an  order  of  the  Commis- 
sioners the  visits  are  permitted  to  be  made  less  fi-equently. 
This  permission  is  not,  as  a  rule,  accorded  luitil  the  patient 
has  been  visited  once  by  a  Commissioner. 

*  (3,)  He  must  now  also  sign  a  certificate  according  to  the 
form  already  given,  when  mechanical  restraint  is  used. 

*  (4,)  When  the  person  in  charge  is  not  a  medical  practitioner, 
the  medical  attendant  must  keep  a  full  daily  record  of  cases 
where  mechanical  restraint  is  used,  and  transmit  it  to  the  Com- 
missioners quarterly. 

*  (5,)  Mechanical  restraint  must  now  only  be  used  for  medical 
or  surgical  reasons,  or  to  prevent  the  lunatic  injuring  himself 
or  others.  Wilful  contravention  of  these  regulations  as  to 
restraint  is  a  misdemeanour. 

*  (6,)  The  medical  attendant  of  every  single  patient  must  at 
the  expiration  of  one  month  after  the  reception  of  the  patient, 
send  to  the  Commissioners  a  report  as  to  the  mental  and  bodily 
condition  of  the  patient  in  such  form  as  they  may  direct. 

(7,)  The  medical  attendant  must  at  each  visit  enter  in  the 
medical  \isitation  book  (for  the  form  of  which,  see  under  the 
■'  Duties  of  person  having  care,  etc.,"  ante),  the  date  of  each  of  his 
visits,  and  a  statement  of  the  several  particulars  required  as  to 
the  condition  and  circumstances  of  the  patient  and  of  the 
house. 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.         289 

*  Making  an  untrue  entry  in  the  medical  visitation  book  is  a 
misdemeanour,  and  failure  to  comply  with  the  regulations  as  to 
the  entries  therein,  entails  a  penalty  not  exceeding  £5. 

(8,)  He  must  on  the  10th  January,  or  within  seven  days 
thereof  in  every  year,  report  in  writing  to  the  Commissioners, 
the  state  of  health,  mental  and  bodily,  of  the  patient,  and  such 
other  circumstances  as  may  be  deemed  necessary  to  be  communi- 
cated. Such  annual  report  should  give  all  these  particulars  fully, 
even  although  no  change  may  have  occurred  since  the  previous 
report. 

■''■(9,)  By  sect.  7  of  the  Lunacy  Act,  1891,  an  order  for  the 
reception  of  any  patient  shall  remain  in  force  for  one  year,  after 
that  for  two  years,  and  after  that  for  three  years,  then  for 
successive  periods  of  five  years,  provided  the  medical  attendant 
report  specially  to  the  Commissioners  as  to  the  bodily  and  mental 
state  of  the  patient,  and  certify  that  the  patient  remains  of 
unsound  mind,  and  is  a  proper  person  to  be  detained  under  care 
and  treatment.  This  special  report  must  be  sent  not  more  than 
a  month,  and  not  less  than  seven  days  before  the  end  of  each 
period.  If  the  lunatic  has  been  so  found  by  inquisition,  the 
above  periods  must  date  from  May  1st,  1890,  and  the  reports  are 
to  be  sent  to  the  Masters. 

•••  (10,)  The  person  making  the  special  report,  must  give  the 
Commissioners  any  further  information  concerning  the  patient 
they  may  require. 

•'"  Knowingly  to  detain  a  patient  after  the  reception  order  has 
expired,  is  a  misdemeanour.  This  applies  to  the  person  who  has 
charge  of  the  patient. 

'^'  An  order  of  transfer  is  not  deemed  a  reception  order  under 
this  section,  and  the  original  reception  order,  unless  continued, 
will  expire  at  one  of  the  above-mentioned  periods. 

*(11,)  The  Commissioners  may  at  any  time  require  from  the 
medical  attendant  of  a  single  patient  a  report  in  writing  as  to 
the  patient,  in  such  form  and  specifying  such  particulars  as  the 
Commissioners  direct,  and  such  report  shall  be  in  addition  to 
any  periodical  reports  required  to  be  sent  to  the  Commissioners. 

*■  (12,)  In  the  event  of  the  death  of  the  patient,  the  medical 
practitioner  who  attended  him  in  his  last  illness,  must  prepare 
and  sign  a  statement  of  the  cause  of  death  and  the  duration  of 
the  disease  of  which  the  patient  died. 

""  (13,)  This  statement  must  be  entered  in  the  medical 
visitation  book  and  a  copy  of  the  statement,  certified  by  the 
person  in  charge  of  the  patient,  must  be  transmitted  by  him 
to  the  ..coroner  for  the  county  or  borough,  within  two  days  after 
the  death. 

19 


290         LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

*  for:m  op  notice  and  ceetifigate  to  be  sent  to  the 

COM:\riSSIONERS  within  FORTY-EIGHT  HOURS  OF 
THE  DEATH  OF  THE  PATIENT. 

I  hereby  give  you  notice  that a  Private 

Patient  received  into  this  house  on  the day  of 

189     died  therein  on  the day  of 189 

(Signed) 


Proprietor    (or    Superintendent  of) House _^ 

Dated  this ^  day 189 

*  (li,)  And  I  further   certify  that was  present  at 

the  death  of  the  said and  that  the  apparent  cause  of 

death  of  the  said [ascertained  by  post  mortem 

examination  (if  so)  ] was 

( Signed) 

I\Iedical  Attendant  of  the  said 


To  the  Commissioners  in  Lunacy. 

"^^In  Medical  Statement  (p.  288)  for  the  Avords  "  received  into 
this  house  on  "  substitute  the  "words  "  the  patient  mentioned  in 
the  Notice  of  Admission  dated.'^ 

The  offices  of  the  Commissioners  in  Lunac}""  are  at  19,  "Whitehall 
Place,  London,  S.W. 

Statutory  forms,  books,  etc.,  may  be  obtained  from  Messrs. 
Knight  &  Co.,  90,  Fleet  Street,  London,  as  well  as  from  the 
publishers  already  mentioned. 

PERSONS    FOUND    LUNATIC    BY    INQUISITION 
(CHANCEEY  PATIENTS). 

The  Judge  in  Lunacy  may  upon  application  direct  an  inquisition 
Avhether  a  person  is  of  unsound  mind  and  incapable  of  managing 
himself  and  his  affairs.  For  this,  medical  affidavits  and  medical 
evidence  are  required.  The  medical  affidavits  must  be  divided 
into  distinct  paragraphs,  but  this  is  generally  attended  to  by  the 
lawyer  managing  the  case.  Lender  certain  circumstances  the 
inquiry  is  held  before  a  jury. 

When  the  property  does  not  exceed  £2000  in  value  or  the 
income  thereof  £100  per  annum,  the  Judge  in  Lunacy  may 
(if  the  person's  insanity  and  incapacity  are  proved  to  his  satis- 
faction) allow  it  to  be  dealt  Avith  for  the  maintenance  of  the 
l)atient  without  an  inquisition.  When  the  property  is  under 
£200  in  value,  any  county  court  judge  of  the  patient's  district  may 
authorise  the  clerk  of  the  guardians,  a  relieving  officer,  or  other 
person  to  deal  with  it. 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  291 

A  chancery  patient  can  be  admitted  into  any  asylum,  or  as  a 
single  patient  into  any  unlicensed  house,  without  medical  certifi- 
cates ;  an  order  signed  by  the  committee  of  the  person,  mth  an 
office  copy  of  the  order  for  the  appointment  of  such  committee 
annexed  thereto  is  sufficient  authority  for  the  reception  of  such 
patient ;  in  cases  where  no  committee  of  the  person  has  been  ap- 
pointed, the  patient  may  be  sent  to  an  asylum,  etc.,  by  order  of 
one  of  the  Masters  in  lunacy. 

The  individual  (unless  he  is  the  committee  of  the  person)  Avho 
undertakes  the  care  of  a  chancery  patient  in  his  house  for  profit, 
is  liable  to  the  same  responsibilities  and  duties  as  are  enforced 
in  the  case  of  a  single  private  patient. 

The  fortnightly  visitation  of  the  medical  attendant  is  not  re- 
quired in  the  case  of  single  chancery  patients.  The  periodical 
reports  (see  ante)  should  be  sent  to  the  Masters  in  lunacy,  in- 
stead of  the  Comissioners  in  lunacy. 

Single  chancery  patients  are  visited  at  least,  four  times  every 
year  for  the  two  years  following  the  inquisition  by  one  of  the 
Lord  Chancellor's  visitors,  and  afterwards  at  least  t'vvice  eacli 
year  (the  intervals  between  the  visits  never  to  exceed  eight 
months),  and  at  least  once  every  year  by  one  of  the  Commissioners 
in  lunacy. 

UNCERTIFIED    LUNATICS. 

Any  person  who  keeps  ^vithout  profit  an  uncertified  insane 
patient,  may  be  required  by  the  Commissioners  to  send  reports 
by  a  medical  practitioner  of  the  mental  and  bodily  condition  of 
the  patient  and  also  to  send  other  particulars.  The  Commissioners 
may  visit  such  patient  and  exercise  all  their  powers  except  those 
of  discharge.  They  may  report  to  the  Lord  Chancellor  who  may 
discharge  the  patient,  oi-  remove  him  to  an  asylum. 

PAUPER   LUNATICS. 

A  pauper  patient  is  defined  as  one  who  is  "  maintained  Avholly 
or  in  part  by  any  parish,  union,  county,  or  borough." 

When  a  patient  is  unal)le  to  meet  the  expense  of  certification, 
and  of  maintenance  in  a  private  asylum,  or  as  a  private  patient 
in  a  county  asylum  (12/-  a  week  and  upwards),  the  best  method  is 
to  refer  the  friends  to  the  relieving-officer  who  will  see  to  the 
patient's  certification,  visitation  by  the  union  medical  officer,  or,  in 
case  of  urgency,  immediate  and  temporary  admission  into  the 
workhouse.  For  such  admission  to  be  legal  there  must  be  proper 
accommodation  in  the  workhouse,  and  the  patient  (according 
to  Sect.  20,  Lunacy  Act,  1890)  must  not  be  detained  more  than 
three  days,  proceedings  to  be  taken  in  the  meantime  to  have  him 


292  LEGAL   REGULATIONS   AND   FORENSIC  PSYCHIATRY. 

legally  certified.  When  the  union  medical  officer  becomes  aware 
of  the  presence  of  a  pauper  lunatic  in  his  district,  he  must  give 
written  notice  of  the  fact  to  the  relieving  officer  Avithin  three 
days,  or,  in  the  absence  of  a  relieving  officer,  to  the  overseer. 
The  relieving  officer,  or  when  there  is  no  relieving  officer,  the 
overseer  who  comes  to  such  knowledge  by  this,  or  other  means, 
must  within  three  days  give  notice  to  a  justice  of  the  county  or 
borough  in  Avhich  the  patient  is  situated.  A  justice  must  not  now 
sign  an  order  for  the  reception  of  a  pauper  into  an  asylum,  etc., 
or  a  workhouse,  until  he  is  satisfied  that  the  alleged  pauper  is 
either  in  receipt  of  relief,  or  in  such  circumstances  as  to  require 
relief  for  his  proper  care.  A  person  visited  by  a  medical  officer 
of  the  union  at  the  expense  of  the  union,  is  deemed  to  be  in 
receipt  of  relief.  An  order  for  the  reception  of  a  pauper 
or  wandering  lunatic  into  an  asylum,  etc.,  cannot  now  be  signed 
by  an  officiating  clergyman  (as  such),  and  a  relieving  officer  or 
overseer,  but  must  ordinarily  be  signed  by  a  magistrate,  who  must 
be  satisfied  that  there  is  no  room  in  the  piiblic  asylums  of  the 
patient's  county  before  the  said  patient  can  be  legally  sent  to 
another  county  or  to  a  private  asylum  as  a  pauper  patient.  Two 
or  more  Commissioners  may  call  in  a  medical  practitioner,  and  by 
order  direct  a  pauper  lunatic  to  be  received  in  an  institution  for 
the  insane.  See  p.  273  as  to  chairman  of  board  of  guardians  sign- 
ing orders.  There  is  only  one  medical  certificate  required  for  an 
insane  pauper,  and  it  is  essentially  the  same  as  those  required  for 
a  private  patient.  There  are  no  urgency  orders  or  certificates  and 
no  "  petition."  The  statement  only  differs  in  one  or  two  particu- 
lars, e.g.,  the  insertion  of  the  union  to  which  the  pauper  patient  is 
chargeable,  and  the  omission  of  the  name,  etc.,  of  the  usual  medical 
attendant ;  it  is  signed  by  the  relieving  officer  or  overseer. 

53  Vict.  c.  5,  Sched.  2.— Form  12. 

ORDER    FOR    RECEPTION     OF    A    PAUPER    LUNATIC,    OR 
LUNATIC    WANDERING    AT    LARGE. 


tient.^'^'''^  °*  ^''"    ^. leaving  called 

(al)  Eesidenceor     ,                    .   , 
Occupation.  to  my  assistance 


*  If  not  "in  re- 
ceipt   of    relief"    of a  duly  Qualified  medical  practitioner, 

strike    out    these 

''"i'n'ln  receipt  of  ^"^^  ^^"^g  satisfied  that  (a) _  _ 

r  ellef  s  trike  out  the 

words  in  brackets,  (ci/) 

(b)  Lunatic  or  an 

idiot  ora  parson  of  is  a  pauper  in  receipt  of  relief^' 

unsound  mind.  '-       ^  '• 

order  dii4^c1is  the    [oi'  "^  sucli  circumstances  as  to  require  relief  for  li     proper 


LEGAL  REGULATIONS  AND  FORENSIC  PSYCHIATRY. 


293 


is  a  lunatic,  and  was  wandering  at  large,  and  is  a  proper 
]Derson  to  be  taken  charge  of  and  detained  under  care  and 

treatment  (c) 

hereby  direct  you  to  receive  the  said_ 


as  a  patient  into  your  (cZ) 

is  a  statement  of  particulars  respecting  the  said_ 

(Signed) _^_ 


Subjoined 


lunatic  to  be  re-    care  and  maintenance  fl  and  that  the  said 

ceived    into    any  '  '  

asylum,  other  than     .         ,,,  t'  ,     -,  ■, 

an  asylum  of  the    is  a  (b) and  a  proper  person  to  be  taken 

county  or  borough 

i^h^or^piace^from    charge  of  and  detained  under  care  and  treatment,  or  that 
which  the  lunatic 

is  sent  is  situate,    (a) 

or  into  a  registered  

hospital  or  licen- 
sed house,  it  shall 

state  that  the  jus- 
tice making  the 
order  is  satisfied 
that  there  is  no 
asylum  of  such 
county  or  borough 
or  that  there  is  a 
deficiency  of  room 
in  such  asylum  ;  or 
(as  the  case  may 
be)  the  special  cir- 
cumstances, by 
reason  whereof 
the  lunatic  cannot 
conveniently  be 
taken  to  any  asy- 
lum for  such  first- 
mentioned  county 
or  borough. 

id)  Asylum  or 
hospital  or  house. 

(e)  The  superin- 
tendent of  the  asy- 
lum for  the  county 

or  borough  of : 

or  the  lunatic  hos- 
pital of ;  or 

proprietor  of  the 
licensed  house  of 

;    describing 

the  asylum,  hospi- 
tal, or  house. 

Under  certcain  circumstances  (accommodation,  suitable  con- 
dition of  patient,  etc. )  a  pauper  lunatic  may  be  detained  in  a 
workhouse  for  more  than  fourteen  days  against  his  will,  on 
the  order  of  a  magistrate,  such  order  being  made  upon  the 
application  of  the  relieving  officer,  supported  by  a  medical 
certificate  signed  by  a  practitioner  not  being  an  officer  of  the 
workhouse,  and  by  the  certificate  of  the  workhouse  medical  officer. 
The  latter  certificate  enables  the  workhouse  authorities  to  detain 
the  patient  for  fourteen  days  from  its  date,  against  his  will,  as  also 
does  the  temporary  removal  order  of  a  justice. 

Pauper  lunatics  not  recovered,  and  chronic  harmless  pauper 
lunatics  may,  under  certain  circumstances,  be  removed  to  and 
kept  in  a  workhouse,  the  chronic  cases  remaining  on  the  books  of 
the  asylum.  A  pauper  lunatic  may  be  boarded  out  with  a 
relative  or  friend,  by  the  authorities  of  an  asylum,  his  main- 
tenance being  paid  for  by  the  guardians.  The  allowance  to  the 
friend  must  not  exceed  the  cost  of  maintenance  in  the  asylum. 

An  order  for  the  reception  of  a  patient  as  a  pauper  authorises 
his  detention  if  he  should  be  afterwards  classified  as  a  private 
patient,  and  vice  versa. 


A  Justice  of  the  Peace  for 
Dated  the day  of 


189 


To  {e)_ 


294         LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY 

LUNATICS  (XOT  PAUPERS)  NOT  UNDEE  PROPER  CARE 

AND  CONTROL,  OR  CRUELLY  TREATED 

AND    NEGLECTED. 

Am"  person  kno^nng  of  such  a  lunatic  should  acquaint  a  con- 
stable, overseer,  or  relieving  officer  of  the  district  or  parish  who 
must  give  information  on  oath  of  the  presence  of  such  lunatic  to 
a  justice  within  three  days.  When  a  particular  relieving  officer 
is  directed  to  do  the  duties  in  respect  of  lunatics,  every  other 
relieA'ing  officer  must  report  to  him.  When  a  specially  appointed 
justice  (seep.  273)  is  informed  by  an}' person  on  oath  that  there  is 
such  a  lunatic  in  his  jurisdiction  he  may  'sdsit  him,  or  authorise 
two  medical  practitioners  to  do  so,  examine,  and  certify.  The 
justice  after  calling  to  his  aid  two  medical  practitioners,  maj^ 
make  an  order  for  the  reception  of  the  lunatic  into  an  asylum. 
The  justice  may  suspend  the  execution  of  his  order  for  14  clays. 
The  medical  practitioners,  or  either  of  them,  ma}^  also  require  the 
suspension  of  the  execution  of  the  order,  if  the  patient  is  unfit 
physically  for  removal.  In  the  latter  case  he  may  be  received  in 
the  asylum  -within  three  days  after  the  date  of  a  medical  certifi- 
cate stating  that  he  is  fit  to  be  remoA'ed.  A  relative  or  friend 
may  take  charge  of  him  if  the  justice  is  satisfied  that  he  (the 
patient)  Avill  be  well  treated. 

WANDERING    LUNATICS    (PERSONS  DEEMED 
LUNATICS,  WANDERING  AT  LARGE). 

The  constable,  etc.,  must,  immediately  he  knows  of  such  a  person 
(whether  he  be  a  pauper  or  not)  being  in  his  district,  apprehend 
him  and  take  him  before  a  justice  having  jurisdiction  in  the 
county  or  borough.  The  justice  on  receiving  information  on 
oath,  may  compel  the  constable,  etc.,  to  bring  such  person  before 
him  or  some  other  justice  ha-\dng  jurisdiction  in  the  district.  One 
medical  certificate  is  required.  Regulations  as  to  suspension  of 
order,  as  in  case  of  lunatic  not  under  proper  care  and  control. 

It  is  now  provided  b}'  Lunacy  Act,  1891,  that  this  and  the 
preceding  class  of  patients  are  to  be  classified  as  paupers  until  it 
is  ascertained  that  they  are  entitled  to  be  classified  as  jjrivate 
patients. 

CRIMINAL   LUNATICS. 

1.  iJangerons  Lunatics. 

A  person  mentally  deranged  discovered  under  circiimstances 
that   denote  a   purpose    of    committing    some    crime,    may   be 


LEOAL  REGULATIONS'  AND   FORENSIC   PSYCHIATRY.  295 

examined  by  two  justices  with  medical  assistance,  and  sent 
to  the  county  asyhim,  or,  if  in  a  fit  condition,  handed 
over  to  a  friend  who  agrees  to  become  responsible  for  his 
safe  care. 

2.  Prisoners  found  to  hare  been  insane  at  the  time  of  commit- 
ting their  offences  (whether  treason,  murder,  felony,  or  mis- 
demeanour). 

If  the  jury  acquit  the  prisoner  on  the  ground  of  insanity  at  the 
time  the  offence  was  committed,  he  is  ordered  by  the  Court  to  be 
kept  in  custody  until  an  order  is  made  by  the  Crown  for  his  safe 
custody  during  Her  Majesty's  pleasure,  when  he  ■will  be  removed 
to  a  specified  place  (noAV  generally  Broadmoor  Asylum).  Lunatics 
guilty  of  the  less  grave  of  the  above  offences  may  be  sent  to 
a  county  asylum  or  given  into  the  custody  of  a  responsible 
friend. 

Eecently  a  lunatic  pleaded  guilty  to  felony  and  was  sentenced 
by  the  judge  to  imprisonment  and  penal  servitude,  "for  the 
jnisoner's  own  protection  " .' 

3.  Frisoners  found  to  he  insane  during  custody  before  trial. 

The  justices  or  directors  must  make  inquiry  as  to  the  sanity  of 
the  criminal  with  the  aid  of  two  diily  qualified  medical  prac- 
titioners. If  they  certify  him  insane,  the  Secretary  of  State  may 
direct  him  to  be  removed  to  an  asylum. 

4.  Frisoners  foimd  to  be  insane  at  the  time  of  trial. 

If  a  prisoner  appears  to  be  insane  on  arraignment,  and  a 
jury  impanelled  to  try  the  question  of  his  sanity  find  him 
insane  the  trial  will  not  proceed,  but  the  prisoner  ^Wll  be  kept  in 
custody  till  Her  Majesty's  pleasure  be  known.  The  Crown  ma}^ 
then  make  an  order  for  his  safe  custody  at  a  specified  place, 
during  Her  Majesty's  pleasure. 

If  a  prisoner  is  found  insane  at  the  trial  the  proceedings  are  as 
above.  If  a  prisoner,  brought  before  a  court  to  be  discharged  for 
Avant  of  prosecution,  appears  to  be  insane,  a  jury  is  impanelled 
and  the  proceedings  are  as  above. 

5.  Frisoners  found  to  be  insane  during  Custody  after  Conviction. 
Where     there    is  reason  to.  suppose  that    a  jorisoner   under 

sentence  of  death  is  insane,  the  Secretary  of  State  may  order  an 
inquiry  by  medical  men  as  to  his  insanity,  and  direct  his  removal 
to  an  asylum  for  insane  prisoners  (Broadmoor  Criminal  Lunatic 
Asylum).  If  the  prisoner  is  confined  for  any  other  criminal 
offence,  the  inquiry  may  be  ordered  by  two  of  the  visiting  justices 
of  the  prison  in  which  he  is  confined,  or  two  justices  for  the 
county,  etc.,  in  which  he  is,  if  not  in  a  prison  to  which  visiting 
justices  are  appointed. 


296  LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

STATEMENT   BESPECTING   CRIMINAL   LUNATICS  TO   BE 
PILLED  UP  AND  TRANSMITTED  TO  THE  MEDICAL   SUPERIN- 
TENDENT WITH  EVERY  CRIMINAL  LUNATIC. 

Name^ 

Age. 

Date  of  Admission  ^^^ 

Former  occupa.tion _^ 

From  whence  brought       

Married,  single,  or  widowed 

How  many  children ■. 

Age  of  youngest 

Whether  first  attack 


When  previous  attacks  occurred_ 

Duration  of  existing  attack 

State  of  bodily  health 


Whether  suicidal  or  dangerous  to  others_ 
Supposed  cause 


Chief  delusions  or  indications  of  insanity_ 

Whether  subject  to  epilepsy 

Whether  of  temperate  habits 

Degree  of  education 

Religious  persuasion 

Crime  


When  and  where  tried_ 

Verdict  of  jury 

Sentence 


CERTIFICATION  OF  THE  INSANE  IN  SCOTLAND. 

An  urgent  case  may  be  admitted  into  and  detained  in  an 
asylum  for  a  period  not  exceeding  three  days  on  one 
medical  "Certificate  of  Emergency,"  accompanied  by  the 
"  Request  "  of  a  relative  or  friend.  Ordinarily  there  are  required 
two  medical  certificates  the  forms  for  which  are,  with  the 
exception  of  one  or  two  remarkable  verbal  variations,  not 
unlike  those  used  in  England  prior  to  the  passing  of  the  recent 
Lunacy  Bill,  a  "  Statement "  also  somewhat  similar  to  that 
formerly  in  use  in  England,  a  "  Petition "  to  the  Sheriff  or 
Steward,  and  an  "  Order  "  by  that  authority. 

Private  and  pauper  patients  are  certified  and  placed  in 
asylums  in  the  same  way.  The  certifying  medical  men  must 
see  the  patient  on  the  day  of  certification.      The  date  of  the 


LPJGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  297 

petition  must  be  within  fourteen  clear  clays  following  the  dates 
of  the  medical  certificates,  and  the  order  must  be  dated  within 
fourteen  days  prior  to  the  reception  of  the  lunatic.  Where  there 
is  property  to  be  administered  two  medical  certificates  as  to  the 
patient's  insanity  and  incapacity,  and  a  petition  from  a  near 
relative  stating  the  amount  of  the  property,  are  presented  to  a 
judge  of  the  Court  of  Session,  and  after  they  have  been  intimated 
in  the  Court  for  eight  days,  if  there  is  no  opposition  a  Omxitor 
Bonis  is  appointed  to  manage  the  lunatic's  property  and  act 
for  him. 

"  A  patient  can  be  treated,  with  a  view  to  cure,  anywhere  out 
of  an  asylum  for  twelve  months  without  formal  certificates,  if  a 
medical  opinion  to  that  effect  and  intimation  is  sent  to  the 
Commissioners  in  Lunacy"  (Clouston,  "Ment.  Dis."  1st  Ed. 
p.   610). 

If  a  lunatic  {single  patient)  is  detained  in  a  private  house  for 
more  than  a  year,  or  for  profit,  an  order  from  the  Sheriff  or  the 
sanction  of  the  Board  must  be  obtained.  If  the  lunatic  is  a 
pauper  the  inspector  of  the  poor  applies  for  the  order,  and  the 
Sheriff  may  grant  it  on  one  medical  certificate.  On  January  1st, 
1891,  23 •?  per  cent,  of  all  pauper  lunatics  were  "  hoarded  out " 
in  private  chvellings.  Voluntary  hoarders  can  be  received  into 
asylums.  The  written  consent  of  a  Commissioner  must  be 
•btained  previously.     For  this  the  boarder  must  apply  in  writing. 

N.B. — This  Form  shall  remain  in  the  keeping  of  the  ] 

Superintendent  of  the  Asylum,  after  the  Order  [  [Form  A.] 

of  the  Sheriff  is  obtained.  ) 

25  and  26  Vict.  Cap.  64,  Sect.  14, 

PETITION    TO    THE    SHERIFF    TO    GRANT   ORDER    FOR    THE 
RECEPTION  OF  A  PATIENT  INTO  AN  ASYLUM. 


Stewarci!^"*'^     °'''     Unto  the  Honoiirablo  the  (a)  of  the  lb) 

(6)  Shire  or  Stew-  of and  his  Substitutes, — 

artry. 

The  petition  of ^' 

humbly  showeth  that  it  appears  from  the  subjoined  State- 
ment and  accompanying  Medical  Certificates  that 


(e)  State  degree    your  Petitioner's  (c) 

of  Relationship  or  . 

other  capacity  in  IS  at  present  m  a  state  of  Mental  Derangement,  and  a 

which    Petitioner 

Btands  to  Lunatic,  proper  person  for  treatment  in  an  Asylum  for  the  Insane. 

May  it  therefore  please  your  Lordship  to  authorise  the 


298 


LEGAL   REGULATIONS   AND   FORENSIC  PSYCHIATRY. 


transmission  of  tlie  said 


and  to  sanction 


into  the  said  Asylum. 


ul)  The  date  of 
the  Petition  must 
be  within  fourteen 
clear  days  follow- 
ing the  dates  of 
the  Medical  Cer- 
tificates, 


To  be  signed  by  the  party  applying^ 


Dated  this 


id)  day  of 


to  the 


admission 


One 


thousand  eight  hundred  and 


STATEMENT. 

If  any  of  the  Particulars  in  this  Statement  he  not  knoicn,  the  fact  to  be  so 

stated. 

1. — Christian  Name  and   Surname  of  Patient    at 
length  ------ 

2. — Sex  and  Age        ----- 

3.— Married,  Single,  or  Widowed 

i. — Condition   of    Life,  and  pre%-ious   Occupation 
(if  any)  .  .  .  .  - 

5. — Religious  Persuasion,  so  far  as  known  - 

6. — Previous  Place  of  .\hode 

7. — Place  where  found  and  examined 

8. — Length  of  time  Insane    -  -  -  - 

9.— Whether  First  Attack     -  -  -  - 

10. -—Age  (if  known)  on  First  Attack  - 

11. — When  and  Where  pre\'iously  under  Examina- 
tion and  Treatment  [name  of  Establishment 
into  which  last  received,  and  Year  of  Recep- 
tion or  approximation  thereto'] 

12. — Duration  of  Existing  Attack 

13. — Supposed  Cause  -  -  -  -  - 

14. — Whether  subject  to  Epilepsy 

15. — -Whether  Suicidal  -  .  -  - 

16. — Whether  Dangerous  to  others    - 

17.  —Parish  or  Union  to  which  the  Lunatic  (if  a 
Pauper)  is  Chargeable 

IS. — Date  of  becoming  Chargeable     - 

19  — Christian  Name  and  Surname,  and  Place  of 
Abode    of   nearest   known  Relative    of    the 
Patient,    and    degree    of     Relationship    (if 
known),  and  whether  any  Member  of  h 
Family   known   to   be   or  to  have  been  In- 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 


299 


20. — Special  circumstances  (if  any)  preventing  tlie  } 
insertion  of  any  of  tlie  above  particulars       -  ( 

I  certify,  that,  to  tlie  best  of  my  knowledge,  the  above  particulars  are 
correctly  stated. 

Dated  this ^day  of 

hundred  and 


One  thousand  eight 


(To  be  Signed  by  the  ixirty  applying)^ 


MEDICAL     CEKTIFICATE. 


(a)  Set  forth  the 
quaiifioation  en- 
titling the  person 
certifying  to  grant 
the  certificate ;  e.g. 
Member  of  the 
Eoyal  College  of 
Physicians,  Edin- 
burgh. 

(6)  Physician  or 
Surgeon,  or  other- 
wise, as  the  case 
may  be. 

(c)  Insert  the 
street,  and  num- 
ber of  the  house 
(if  any),  or  other 
like  particulars. 

(d)  Insert  Desig- 
nation and  Kesi- 
dence,  and  if  a 
Pauper  state  so. 

(e)  Lunatic,  or  an 
insane  person,  or 
an  idiot,  or  a  per- 
son of  unsound 
mind. 

(/)  State  the 
facts. 


(g)  State  the  in- 
formation,       and 
from    whom 
ceived. 


I,  the  undersigned, 
being  a  [a) 


and  being  in  actual  practice  as  a  (6) 

do  hereby  certify,  on  soul  and  conscience,  that  I  have  this 

day,  at  (c) 

in  the  County  of 

separately  from  any  other  Medical  Practitioner,  visited 

and  personally  examined  {d) .__ 

and  that  the  said ; 

a  (e) 

and  a  proper  person  to  be  detained  under  Care  and  Treat- 
ment, and  that  I  liave  formed  this  opinion  upon  the  fol- 
lowing grounds,  viz.  : — 

1.  Facts  indicating  Insanity  observed  by  myself  :  (f) 

2.  Other  Facts  (if  any)  indicating  Insanity  comnumi- 
cated  to  me  by  others  :  {g) 

Name   and   Medical  \ 
Designation         \ 

Place  of  Abode        


Dated  this 


day  of_ 


One  thousand  eight  hundred  and 


The  certifying  medical  men  must  have  no  pecuniary  interest  in 
the  asylum  in  which  the  lunatic  is  to  be  placed ;  but  one  of  them 
may  be  a  medical  officer  of  such  asylum,  provided  it  is  not  a 
private  asylum. 


300         LEGAL  REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

CERTIFICATE     OF    EMERGENCY. 

(This  Certificate  authorises  the  detention  of  a  Patient  in  an  Asylimi  for  a 
period  not  exceeding  three  days  without  any  Order  by  the  Sheriff.) 

(a)  state    medi-    I^  the  undersigned, being  {a) 


eal  qualification,      j-^gj-g^y  certify,  on  soul  and  conscience,  that  I  have  this 

(6)  State  place  of 
examination.  day,  at  (6) in  the  County  of ,  seen  and 

personally  examined ,  and  that  the  said  person 

is  of  unsound  mind,  and  a  proper  Patient  to  be  placed  in 

an  Asylum. 

And  I  further  certify  that  the  case  of  the  said  person 
is  one  of  Emergency. 

{Signed) 


Dated  this day  of ^One 

thousand  eight  hundred  and . 


(The  following  should  be  filled  up  in  every  case  in  which  a  Certificate  of 
Emergency  is  acted  on.) 

I  hereby  request  the  Superintendent  of  the 

to  receive  therein 


to  whom  the  foregoing  Certificate  of  Emergency  refers. 

Relationship  or  other  capacity  ) 

in  which    Applicant  stands  >  ■ 

to  Patient      -  -  i 


Signature  and  Address 
Date 


ORDER  TO  BE  GRANTED  BY  THE  SHERIFF  FOR  THE  TRANS- 
MISSION AND  RECEPTION  OF  THE  LUNATIC. 


(p)  State  wheth-  ^                                                       ,    . 

er  Sheriff,  SheriS-    -t). («)  , 

Substitute,    Stew-  r  ti       /z,i                                                       i: 

ard,   or    Steward-    OI  'lie  (b) ^of 

Substitute. 

(6)  State  wheth-  ^^^''^'ig  ^^^.d  produced  to  me,  with  a  Petition  at  the  in- 

fte.^.nrT''  °'    stance  Of  (c) . 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  301 

(c)  Insert  Name    Certificates  under  the  hands  of 


and  Designation.      ^^^^ ^  ^^^^^  ^^^  Medical  Persons 

duly  qualified  in  terms  of  an  Act,  intituled  "  An  Act  for 

the  Regulation  of  the  Care  and  Treatment  of  Lunatics 

and  for  the  Provision,  IMaintenance,  and  Regulation  of 

Lunatic  Asylums  in  Scotland,"  setting  forth  that  they  had 

(d)  Describe  him,   separately  visited  and  examined  (d) 
and  if  a  Pauper,        ^  ""  ^    '— 


state  so.  and  that  the  said is  a  (e) 

Insane^  P^e^rson,  'or   ^^"^  ^  proper  Person  to  be  detained  and  taken  care  of,  do 
sM '^o^f*'  unsound   HEREBY  AUTHOEiSE  you  to  receive  the  said 

™''^'^'  as  a  patient  into  the  (/■) Asvlum  of 

(/)Pulic,    Dis-  ■" ^  -. 

trict,  Parochial,  Of    and  I  authorise Transmission  to  the  said  Asylum 

Private.  t      , 

accordingly ;  and  I  transmit  you  herewith  the  said  Medi- 
cal Certificates,  and  a  Statement  regarding  the  said 

which  accompanied  the  said  Petition. 

Dated  this day  of One 

thousand  eight  hundred  and . 


'(/1  Pubhc,     Dis- 
teict,  Parochial,  or   To  the  Superintendent  of  the  [g]  Asylum  of 


CERTIFICATION  OF  THE  INSANE  IN  IRELAND. 

/. — Admission  into  Private  Asylums. 

There  are  required  two  medical  certificates,  a  "  statement '" 
and  an  "  order" ;  the  latter  is  signed  by  a  private  individual  who 
may  or  may  not  be  a  relative  of  the  patient.  The  patient  must 
be  admitted  within  seven  days  after  the  date  of  the  medical 
certificates.     (See  Form  below.) 

The  medical  certificates  must  be  signed  and  dated  on  the  day 
the  patient  is  examined.  The  disqualifications  for  signing  are 
practically  the  same  as  in  England  {vide  siqrra).  If  a  patient  has 
been  admitted  on  one  certificate,  another  must  be  obtained  within 
fourteen  days  of  the  date  of  the  first. 

Lunacy  inquisitions,  ordered  by  the  Court  of  Chancery  where 
the  property  of  the  insane,  or  alleged  insane,  person  is  valued  at 
more  than  £1,000,  are  carried  out  as  in  England.  An  inquisition 
taken,  or  a  writ  of  supersedeas  issued,  in  the  one  coimtry  may  be 
acted  upon  in  the  other  under  an  order  of  the  Irish  Lord 
Chancellor  or  the  English  Judge  in  Lunacy. 


302  LEGAL   REGULATIONS   AND   FORENSIC  PSYCHIATRY. 

STATEMENT  AND  OEDER  TO  BE  ANNEXED  TO  THE  MEDICAL 

CERTIFICATES   AUTHORISING  RECEPTION  OF  AN 

INSANE   PERSON. 


The  Patient's  true  Chxistian  and  Sur- 
name at  full  length   - 
The  Patient's  Age 
Married  or  Single 
The  Patient's  previous  occupation  (if  ) 

any)    -  -  -  .  .] 

The  Patient's  previous  place  of  abode 
The  licensed  House  or  other  Place  (if  ) 

any)  in  wliich  the  Patient  was  before  > 

confined  -  -  -  -  ) 

Whether  found  Lunatic  by  Inquisition,  / 

and  Date  of  Commission       -  -  ^ 

Sj)ecial  Circumstance  which  shall  pre-  ] 

vent  the   Patient   being   separately  f 

examined   by  two   Medical   Practi-  i 

tiouers  -  -  -  -  ) 

Special  circumstance  which  exists  to 

prevent  the  insertion  of  any  of  the 

above  particulars 

Sir, — Upon  the  Authority  of  the  above  Statement,  and  the  annexed 

^Medical  Certificates,  I  request  you  will  receive  the  said 

as  a  Patient  into  your  House. 

I  am, 
Name     -----     

Occupation  (if  any)        -  -  -     

Place  of  Abode  -  -  -  - 

Degree  of  Relationship  (if  any)  to  the  ) 

Insane  Person            -            -  -\ 

To ProxDrietor  of  the  Private  Lunatic  Asylum  at 


F0R:\I     of    MEDICAL    CERTIFICATE. 


I,  the  undersigned,  hereby  certify.  That  I  separately  visited  and  per- 
sonally examined the  Person  named  in  the  annexed  Statement 

and  Order  on  the day  of One  Thousand  Eight  Hundred 

and and  that  the  said is  of  unsound  Mind,  and  a  proper 

Person  to  be  confined. 

{Signed)        Name       

Physician,  Surgeon,  or  Apothecary 

Place  of  Abode 


j6£g°The  admission  of  the  Patient  must,  be  within  seven  days  after  the  date 
of  the  Medical  Ceiiiiflcates,  agreeably  to  Act  5  and  6  of  Victoria. 


"Single  Patients'''  maybe  kept  in  unlicensed  houses, but,  unless 
they  are  chancery  lunatics,  they  must  not  be  received  without  the 
above  documents  if  any  profit  is  derived  from  the  charge. 


LEGAL   REGULATIONS   AND   EORENSIC   PSYCHIATRY.  303 

//. — Admission  into  District  Lunatic  Asylums  {District  Hos])itals 
for  the  Insane).     (See  Form  E  beloAv.) 

Privy   Council  Eegulations. 

Rule  XI. — Persons  labouring  under  mental  disease,  for  whom 
papers  of  application  are  filled  up  in  the  prescribed  forms,  to  the 
satisfaction  of  the  Board,  and  who  shall  he  duly  certified  as  insane 
by  a  registered  physician  or  surgeon,  who  shall  state  the  grounds 
on  which  he  forms  his  opinion,  shall  be  admissible  into  District 
Asylums,  after  having  been  examined  by  the  Resident  Medical 
Superintendent,  or,  in  his  absence,  by  the  visiting  physician  or 
surgeon. 

Rule  XVI. — No  patient,  other  than  a  "  dangerous  lunatic  " 
shall  be  admitted  without  the  sanction  of  the  Board,  except  by 
order  of  the  Lord  Lieutenant,  or  the  Inspectors  of  Lunatics  or 
one  of  them,  or  in  case  of  urgency,  when  any  three  Governors  or 
the  Resident  Medical  Superintendent,  or  in  his  absence  the 
visiting  Physician  of  the  asylum  may  admit  upon  their  or  his  own 
authority,  stating  on  the  face  of  the  order,  the  ground  thereof, 
provided  always  that  when  a  patient  has  been  admitted  under 
this  rule,  the  Resident  Medical  Superintendent,  or  in  his  absence 
the  Visiting  Physician,  shall  submit  the  case  to  the  special  con- 
sideration of  the  Board  at  its  next  meeting  for  the  decision  of  the 
Governors  thereon. 

Regulations  of  April  24th,  1885,  as  to  military  patients. — All 
soldiers  serving  in  Ireland  who  shall  be  duly  certified  to  be  of 
unsound  mind,  may  be  temporarily  admitted  into  any  district 
lunatic  asylum. 

FoEJi  E. 

DISTRICT   LUNATIC   ASYLUM.—PORM    OP    APPLICATION    FOR 

ADMISSION. 


No  Patient  can  be  admitted  without  a  previous  application  made  to 
the  Asylum,  and  a  form  of  admission  obtained  which  must  be  acciu'ately 
complied  with. 

The  following  Declarations,  Certificates,  Forms  and  Engagement,  are 
to  be  filled  up  and  transmitted  to  the  Resident  Medical  Superintendent 
previously  to  the  Lunatic  being  sent  to  the  Institution,  and  no  Lunatic 
will  be  received  until  it  shall  be  notified  to  some  of  the  friends  of  the 
Lunatic  that  there  is  a  vacancy  for  his  or  her  reception. 

No  application  will  be  attended  to  which  does  not  state  the  Name, 
Residence  and  Occupation,  and  degree  of  relationship  of  the  two  next 
male  relatives,  and  the  next  female  relatives  of  the  Patient  (when  such 
exist),  according  to  the  annexed  form,  when  it  is  possible  to  give  those 
particulars. 

It  is  requested  that  a  person  will  accompany  the  Patient  to  the  Asy- 
lum, who  is  able  to  give  the  best  information  resx^ecting  his  or  her  disease, 
former  mode  of  life,  etc.  :  and  it  is  expected  that  the  Lunatic  will  be  pro- 
perly clad. 

Patients  are  not  admitted  on  Sundays. 


304 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY 


DECLAEATION. 


County  of_ 


To  wit 


I, 


of 


in  the  County  of 


declare  that 

County  or  City  of 

that  the  said 

to  support 

that 


by  Occupation  a 
_residing  at 


do  solemnly  and  sincerely 

in  the  Parish  of and 

and 


is  Insane,  and  has  been  so  for 


^is  destitute,  and  has  no  friend  who  is  willing  or  able 

in  a  Private  or  other  establishment  for  insane,  and 

has   been  resident  in  the  County  or  City   of for 


and  that  the  information  in  the  annexed  form  is  correct. 


And  I  make  this  solemn  Declaration,  conscientiously  believing  the 
same  to  be  true,  and  by  virtue  of  the  provisions  of  an  Act  made  and  passed 
in  the  Sixth  Year  of  the  Eeign  of  his  late  Majesty  King  William  the  Fourth 
(5  &  6  Wm.  IV.,  c.  62),  intituled  an  "  Act  to  Repeal  an  Act  of  the  present 
Session  of  Parliament,  intituled  an  '  Act  for  the  more  effectual  Abolition 
of  Oaths  and  Affirmations,  taken  and  made  in  various  departments  of  the 
State,  and  to  substitute  Declarations  in  lieu  thereof,  and  for  the  more 
entire  suppression  of  voluntary  and  extra-judicial  Oaths  and  Affidavits, 
and  to  make  other  provisions  for  the  abolition  of  unnecessary  Oaths.'" 

Declared  to  bv  mc 


Stamp  to  the 
value  of  One 
Shilling  to  be 
affixed  here. 


Made  and  Subscribed  at in  said  County,  or 

City  of  _    before  Me,  a  Justice  of  the 

Peace  for  said  County,  or  City,  this day 

of 18     . 

.  Justice. 


TJie  following  Form  must  be  filled  ■zyj  by  the  Friends  of  the  Lunatic. 
Names  of  the  Two  kext  Akin  to  the  Lunatic. 

Relative's  Names  -  -  - . 

Residence        .  -  -  -     

Occupation     -  -  -  - 

Degree  of  Relationship         -  - 

Lunatic's  Age    -  -  -  -     _       

Religion  -  -  -  -. 

Original  disposition  and  habits  of  life 

Place  of  Birth    -  -  -  -     _         

Place  of  Abode  -  -  .     .        - ^ : 

Occupation  or  Trade      -  -  - . ^ 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  305 

Whether  Single  or  Married,  and  if  a  1  ^ 

Female  whether  she  has  had  Child-  [ 

ren      -  -  -  -  -  ) 

Whether  any  near  Relative  has  been  } 
Insane  -  -  -  -  \ 

How  long  ill,  and  if  violent      -  - 

What  Education 


CERTIFICATE   OF  A   MAGISTRATE    AND   CLERGYMAN,    OR 
POOR   LAW   GUARDIAN. 


We  certify  hereby  that  we  have  personally  inquired  into  the  case  of 

the  above-named who  is  represented  as  residing  in  the  Parish 

of ,  and  County  or  City  of and  we  believe to  be 

a  Lunatic  in  destitute  circumstances,  and  that  the  statement  of 

is  correct. 

Name  of  Magistrate 


Name  of  Clergyman  or  Poor  Law  Guardian_ 


Date 


MEDICAL   CERTIFICATE. 


I  certify  that ,  whom  I  visited  on day  of 

and  into  whose  case  I  specially  and  personally  inquired,  is  now  insane, 

and  I  am  of  opinion,  from  the  nature  of malady,  that is 

a  fit  subject  for  speedy   admission  into   the District   Lunatic 

Asylum,  and  that  I  have  filled  up  the  annexed  form  to  the  best  of  my 
knowledge  and  belief. 

Signature  of  Physician 

Residence 

Date 


Species  of  Insanity 

Probable  Cause  of  Derangement 

Prominent  Symptoms  - 

Whether  affected  by  Bodily  Disease  - 

Whether  Idiotic  or  Epileptic    - 

Facts  indicating  Insanity  as  observed 
by  me  .  .  -  . 

Signature 


20 


306 


LEGAL   REGULATIONS   AND  FORENSIC   PSYCHIATRY. 


To  the  Board  of  Governors  of 

District  Lunatic  Asylum. 

Gentlemen, — In  consideration  of  your  receiving  into  and  maintaining 
in  the  above  Asylum as  a  Patient,  I  hereby  undertake  that  with- 
in one  week  from  my  receiving  notification  from  the  Inspectors  of  Lunatic 

Asylmns  or  the  Board  of  Governors,  that  the  said is  no  longer  a 

fit  person  to  be  accommodated  therein,  I  shall  remove  the  said 


from  the  Asylum,  and  in  the  event  of  my  failing  so  to  do,  I  hereby  agree 
to  be  responsible  to  the  Board  for  any  expense  they  may  incur  in  having 
the  said removed  therefrom,  and  also  for  all  the  costs  of  ^^^  main- 
tenance in  the  Asylum  after  the  expiration  of  said  week,  and  until  g^g  shall 
have  been  finally  removed  therefrom. 


Signature, 


6d.  Stamp. 


COMMITTAL   WAREANT   OF   A   DANGEROUS   LUNATIC    OR   A 
DANGEROUS    IDIOT. 

To  be  Signed  hy  Tivo  Magistrates  sitting  together. 


(ahc)  Here  state  Name 
and  Address  of  each  In- 
formant, and  Date  of  each 
Information. 

(d)  Here  state  Name  of 
Lunatic  or  Idiot. 

(e)  Here  state  Place  of 
Abode  of  Lunatic  or  Idiot. 

(/)  Here  state  Position  in 
Life  of  Lunatic  or  Idiot, 

(g)  Here  state  Name  of 
Place  and  County,  County 
of  a  City,  County  of  a  Town, 
City,  or  Town  as  case  may 
he,  in  which  discovery  and 
apprehension  took  place. 

(?!)  Here  state  the  facts 
from  which  it  appears 
that  the  person  was  dis- 
covered and  apprehended 
under  circumstances  de- 
noting a  derangement  of 
mind,  etc. 

(i)  Here  state  Name  of 
Medical  Officer. 

{j )  Here  state  Address  of 
Medical  Officer. 


In  pursuance  of  Act  30  &  31  Vict.,  c.  118. 


County  of_^ 


to   wit 


)  By  Two  or  more  Justices 
>  of  the  Peace  in  and  for 
)      said  County. 


To  the  Resident  Medical  Superiutendent   of 
the  Asylum  at 

WJiereas,  by  Information  sworn  before  us  by 


(a)_ 

of  (&) 

on  the  (c) 

it  has  been  proved  to  our  satisfaction  that  {d) 


day  of_ 


18 


of  (e). . 

by  occupation  a  (/)^ 


LEGAL    REGULATIONS    AND    FORENSIC    PSYCHIATRY. 


30^ 


(fc)  U  the  Medical  Officer 
wlaom  the  Justices  call  to 
their  assistance  is  the  only 
Medical  Officer  of  the  Dis- 
pensary District  in  which 
the  Justices  shall  be  at  the 
time,  then  fill  the  blank 
left  at  k  as  follows  in 
italics,  and  insert  at  I  the 
name  of  such  Dispensary 
District,  and  at  m  the 
County,  County  of  a  City, 
County  of  a  Town,  City,  or 
Town  in  which  such  Dis- 
pensary District  is  situate, 
namely,  "Tlie  Medical  Of- 
ficer of  the  1 Dispensary 

District,  situate  inra , 

and  being  the  Dispensary 
District  in  which  ice  now 
are." 

If  there  is  more  than  one 
Medical  Officer  of  the  Dis- 
isensary  District  in  which 
the  Justices  shall  be  at  the 
time,  the  nearest  available 
Medical  Officer  of  such 
District  is  to  be  called  by 
the  Justices  to  their  assis- 
tance; and  in  that  eventthe 
blank  left  at  7risto  be  filled 
up  as  follows  in  italics— in- 
serting at  I  the  name  of 
such  Dispensary  District, 
and  at  m  the  County,  Coun- 
ty of  a  City,  County  of  a 
Town,  City,  or  Town  in 
which  such  Dispensary 
District  is  situate,  namely, 
"  The  nearest  availaWe  Med- 
ical OMcer  of  the  1 Dis- 

pensary  District  situate  in 
m ,  and  being  the  Dis- 
pensary District  in  lohich 
we  now  are." 

If  there  is  no  Medical 
Officer  or  no  available 
Medical  Officer  of  the  Dis- 
pensary District  in  whicli 
the  Justices  shall  be  at  the 
time,  the  nearest  available 
Medical  Officer  of  any 
neighbouring  Dispensary 
District  is  to  be  called  by 
the  Justices  to  their  assist- 
ance; and  in  that  event 
the  blank  left  at  7i-  is  to  be 
filled  up  as  follows  in 
italics — inserting  at  I  the 
name  of  the  Dispensary 
District  of  such  Medical 
Officer,  and  at  m  the  Coun- 
ty, County  of  a  City,  Coun- 
ty of  a  Town,  City,  or  Town 
in  which  such  Medical  Of- 
ficer's Dispensary  District 
is  situate,and  at  n  the  name 
of  the  Dispensary  District 
in  which  the  Justices  shall 
be  at  the  time,  and  at  o  the 
County,  County  of  a  City, 
County  of  a  Town,  City,  or 
Town  in  which  the  Dispen- 
sary District  in  which  the 
Justices  shall  be  at  the 
time  is  situate,  namely, 
"The  nearest  available  Med- 
ical OMcer  of  the  1 Dis- 
pensary District  situate  in 
m ,  being  a  neighbour- 
ing Dispensary  District  to 


has  been  discovered  and  apprehended  at  {g)^ 


under  cireiinistances  denoting  a  derangement  of 
mind,  and  a  purpose  of  committing  an  indictable 
crime,  that  is  to  say  (7i) 


And  whereas  we  have  called  to  our  assistaube 


of(i) 

who  is  (Ic) 


And  whereas  the  said  [i) 


has  duly  examined  the  said  {d) 

and  has  duly  certified  by  the  Medical  Certificate 

annexed  hereto  that  the  said 

is  now  a  dangerous  [p) 

And  whereas  we  have  seen  and  examined  the 

said  (fZ) 

and  upon  the  evidence  aforesaid  and  our  view  and 
examination  aforesaid  are  satisfied  that  the  said 

[cl) , 

is  now  a  dangerous  {p) . 


We  therefore  direct  that  the  said  [d] 

shall  forthwith    be    taken    to    the   said   District 

Lunatic  Asylum  at  [q) ^which  is  the 

Lunatic  Asylum  for  the  said  County  (r) 

in  which  County  (r) 

the  said  ((Z) 


was  discovered  and  apprehended  as  aforesaid. 

And  we  hereby,  in  Her  Majesty's  name,  charge 
and  command  you,  the  aforesaid  Resident  Medical 
Superintendent  of  the  said  Asylum  to  receive  and 
detain  in  the  said  Asylum  the  body  of  the  said  {d) 

and  there  safely 

to  keep  until  removed  therefrom,  or  otherwise  dis- 
charged by  due  course  of  law,  and  for  your  so 
doing,  this  shall  be  your  sufficient  Warrant  and 
Authority. 


308  LEGAL   KEGULATIONS   AND   FORENSIC   PSYCHIATRY. 

the  n  Dispensary   I)is- 

'Sti.iit\^ZrSi^ua^  Given  under  our  Hands  and  Seals,  at 

penmry    District    ue    now    ^j^.^ day  of  .18_  . 

(p)   'Lunatic'  or  'Idiot,' 
as  case  may  be. 

iq)  Here  insert  name  of  J  .P.  Seal. 

Asylum. 

()•)    Or  '  County   of    the  ^  ^^  „      , 

City,'   or    'County   of   the  J.P.  Seal. 

Town,'  as  case  may  be. 

The  attention  of  the  ]\Iagistrates  is  particularly  requested  to  the  pro- 
ceedings required  under  the  j)rovisions  of  the  10th  clause  of  the  Aft 
30  &  31  Vict.,  c.  118. 


The  following  Forms  must  be  filled  up  by  the  Medical  Officer  who  has 
personally  examined  the  Lunatic  or  Idiot : — • 

I.— MEDICAL     CEETIFICATE. 
(a)   Here    state  I  certify  that ,  whom  I  visited  on 


as^toe^ca^se '''may    ^^J  °^ '  ^'^^  ^^*°  whose  case   I  specially  and 

^^'  personally  inquired,  is  now  a  dangerous  (a) and 

I  am  of  opinion,  from  the  nature  of  h malady  that  _he 

is  a  fit  subject  for  speedy  admission  into Lunatic 

Asylum,  under  the  provisions  of  the  Act  30  and  31  Vict, 
c.  118,  s.  10. 

Date_ 18 

Signature  of  Medical  Officer 

Residence 


Dispensary  District 


11. —STATEMENT  OF  PARTICULARS  OF  CASE. 

(h)   Here    state    Species  of  Insanity 
tic  or   Idiot,       '-  ■' 


Lunatic  or 

as  the  case  may    Probable  Cause  of  Derangement 

be. 


Prominent  Symptoms  -  -  - 

Whether  affected  by  Bodily  Disease    - 

■Whether  Idiotic  or  Epileptic    -  -     

Facts  indicating  that  the  Patient  is  a  / 

Dangerous  (b) ) 

I  hereby  certify  that  this  Form  is  filled  up  correctly, 
to  the  best  of  my  opinion  and  belief. 

Date 


Signature  of  Medical  Officer_ 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  309 

The  following  Forms  must  be  filled  up  by  the  Friends  of  the  Lunatic 
or  Idiot : — 

If  no  Friends  of  the  Lunatic  or  Idiot  are  known  this  Form  may  be 
filled  up  by  the  police  so  far  as  their  information  will  enable  them  to 
do  so. 

Names  of  the  Two  next  Akin  to  the  Lunatic  or  Idiot. 

Relatives'  Names          -  -  - 

Residence  and  Post  Town  -  - 

Occupation    -            -  -  - 

Degree  of  Relationship  -  - 

Age  of  Lunatic  or  Idiot  -  -        

Religion             -            .  _  . 

Place  of  Birth   -            -  -  - 

Place  of  Abode  -            -  -  - 

Occupation    or    Trade,    and   whether  | 
means  of  his  own  -  -  j  '~ 

Whether  Single  or  Married,  and  if  a  ) 

Female,  whether  she  has  had  Child-  ' 

ren      -  -  -  -  -  ]  - — 

Whether  any  near  Relative  has  been) 
Insane  -  -  -  -, 

How  long  ill,  and  if  violent      -  -     _ 

Habits    of    Life,    Temperate    or    In-  | 
temperate,  etc.  -  -  -  (  "^ 

Education       .  -  -  -  - 

Date  


Signature  _ 


Privy  Council  Regrilations  of  Januarij  26th,  1876,  as  to  the  ad- 
mission of  Paying  Patients  into  District  Lunatic  Asylums. 

Eule  XXVI.  Amended. — No  such  patient  shall  be  admitted 
into  any  district  lunatic  asylum,  so  long  as  there  shall  be  unsatis- 
fied and  legitimate  claims  for  the  admission  of  lunatic  poor  who 
have  no  available  means  of  their  own,  and  whose  friends  are 
unable  or  unAvilling  to  contribute  towards  their  care  and  main- 
tenance in  the  asylum.  The  Resident  Medical  Superintendent 
shall  submit  the  application  for  the  admission  of  every  such 
patient  to  the  Board  of  Governors,  which  application  shall  be  in 
Form  H  hereunto  annexed,  and  shall  state  the  amount  stipulated 
to  be  paid  by  the  friends  of  such  patient  towards  his  support,  and 
shall  be  accompanied  by  a  certificate  signed  by  a  magistrate  and 
a  clergyman,  stating  that  they  are  personally  acquainted  with 
the  circumstances  of  such  patient  and  his  friends,   and  that  to 


310  LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

the  best  of  their  knowledge  and  belief,  such  patient  is  unable  and 
his  friends  are  unable  or  unwilling  to  pay  for  his  care  and  main- 
tenance in  a  jDrivate  lunatic  asylum. 

If  the  Board  of  Governors  shall  approve  of  the  admission  of 
such  patient  uj)on  the  terms  stipulated,  the  Resident  Medical  Super- 
intendent shall  forth-with  submit  the  application  to  the  Inspectors 
of  Lunatics ;  and  no  such  patient  shall  be  admitted  into  any 
district  asylum  without  the  previous  sanction  of  such  Inspectors, 
or  one  of  iheia,  jrroiided  alifays  that  incase  of  patients  admitted  to  the 
Asylum,  otherwise  than  under  the  foregoing  provisions  of  this  Bvle, 
the  Governors  may,  at  any  time  subsequently,  icith  the  sanction  of  the 
Inspectors,  or  one  of  them,  andonreceipA  of  such  a  certificate  as  is  in  the 
last  paragraph  mentioned,  approve  of  terms  of  piayment  to  lie  made 
by  the  friends  of  such  pxttient  for  his  supipjort. 

Every  agreement  for  payment  shall  be  made  with  the  Resident 
Medical  Superintendent,  and  shall  not  exceed  the  average  of  the 
general  cost,  nor  be  less  than  one-half  of  the  average  cost,  for 
the  care  and  maintenance  of  patients  in  the  district  lunatic 
asylum  to  which  such  patient  shall  be  admitted  ;  and  the  amount 
so  stipulated  shall  be  payable  in  advance  by  half-yearly  instal- 
ments, provided  always  that  in  special  cases  the  Board  of 
Governors  may  authorise  such  an  alteration  in  the  charge  as  they 
think  jDroper,  not  less  in  any  case  than  one-fourth  the  average 
cost. 

Paying  patients  shall  be  subject  to  the  same  rules  and  regula- 
tions as  other  patients  in  regard  to  their  treatment,  care,  and 
maintenance.  (General  Rules  and  Regulations  for  the  Manage- 
ment of  District  Lunatic  Asylums  in  Ireland.) 

Poem  H. 

FORM   OP  APPLICATION  POP  THE  ADMISSION  OP   A  PAYING 
PATIENT   INTO   A   DISTPICT   LUNATIC   ASYLUM. 


DECLABATION. 

County  of )      ^  • -i-        j.  •  -. 

To  wit^ '      •^'— residing  at m do 

solemnly  and  sincerely  declare   tliat 


of in  the  County  of has,  for  some  time  past,  been  in  a 

state  of  insanity  and  mental  derangement ;  and  that  the  said is 

unable  to  pay  for care  and  maintenance,  and  has  no  friend  who 

will  support  the  said ^in  a  Private  Lunatic  Establishment,  and 

that ^has  been  a  resident  of  the  said  County  of for  the 

last years;    and  that  the  aimesed  certificates   and  forms  are 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.          311 
correctly  filled  up.    And  I  hereby  undertake  to  pay,  at  the  rate  of  £ 


per  annum,  at  such  times  and  in  such  way  as  the  Board  of  Governors 

may  desire,  for  the  support  and  maintenance  of  the  said in  the 

District  Lunatic  Asylum  until is  discharged  therefrom. 

And  I  make  this  solemn  declaration,  conscientiously  believing  the 
same  to  be  true,  and  by  virtue  of  the  provisions  of  an  Act  made  and  passed 
in  the  Sixth  Year  of  the  Reign  of  his  late  Majesty  King  William  the  Fourth 
(5  &  6  Wm.  IV.,  c.  62),  intituled  '  An  Act  to  repeal  an  Act  of  the  present 
session  of  Parliament,  intituled  "  An  Act  for  the  more  effectual  abolition 
of  Oaths  and  Affirmations,  taken  and  made  in  various  departments  of  the 
State,  and  to  substitute  declarations  in  lieu  thereof,  and  for  the  more 
entire  suppression  of  voluntary  and  extra-judicial  Oaths  and  Affidavits, 
and  to  make  other  provisions  for  the  abohtion  of  unnecessary  Oaths. ' ' ' 

Declared  to  by  me 


Made  and  subscribed  at in  said 

County  of before  me,  a  Justice 

of  the  Peace  for  the  said  County,  this 

day  of 18     . 

Justice. 


MEDICAL  CERTIFICATE  TO  BE  SIGNED  BY  TWO  PHYSICIANS. 


I  certify  that whom  I  visited  on day  of_ 


and  into  whose  case  I  specially  and  personally  inquired,  is  now  insane, 

and  I  am  of  opinion,  from  the  nature  of malady,  that 

is  ai  fit  subject  for  speedy  admission  into District  Lunatic  Asylum, 

and  that  I  have  filled  up  the  annexed  form  to  the  best  of  my  knowledge 
and  belief. 

Signature  of  Physician 

Residence 


Signature  of  Physician_ 
Residence 


Date 


312  LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

Species  of  Insanity       -  -  -  

Probable  Cause  of  Derangement  -     

Prominent  Symptoms  -  -  -      

Whether  affected  with  Bodily  Disease 

Whether  Idiotic  or  Epileptic   -  - 

Facts  indicating  Insanity  as  observed  ) 
by  me  -  -  -  -\ 

(Signature) 


^MAGISTRATE    AND    PARISH   CLERGYMAN'S   CERTIFICATE. 


We  certify  that  we  have  specially  inquired  into  the  case  of 


who  has  resided  in  the  Parish  of County  of for  the  last 

years;    that  we  do  believe to  be  a  lunatic,  and  to  the 

best  of  our  knowledge  and  belief  such  patient  is  unable,  and  that  the 

friends  of  the  said  Lunatic  are  unable  or  unwilling,  to  pay  for 

<3are  and  maintenance  in  a  Private  Lunatic  Asylum,  and  we  recommend 

as  a  fit  subject  for  admission   as   a  paying  patient  into   the 

District  Lunatic  Asylum. 

Given  under  our  hands,  this day  of 18 

Magistrate . 

Parish  Clergyman  of 


Eiif/agement  to  Reviove  to  be  entered  into  by  the  Applicant  for  the  Limatic's 
Admission,  if  required  by  the  Board  of  Governors,  pursuant  to  Rule  15. 


At  any  time,  on  receiving  notification  from  the  Inspectors  or  Board  of 

Governors  of  the District  Lunatic  Asylum  that  the  above-named 

is  no  longer  a  fit  person  to  be  accommodated  therein,  I  hereby  under- 
take to  remove  from  the  Asylum  the  said within  one  week  from  the 

date  of  receiving  such  notification,  as  aforesaid ;  and  if  not  so  removed 
within  a  fortnight,  I  hold  myself  responsible  to  the  Board  for  any  expense 
incurred  by  the  removal  of  said 

Signature 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  313 

THE  FOLLOWING   FORM   MUST  BE  ACCURATELY  FILLED  UP 
ON  BEHALF  OF  THE   PATIENT  BY  APPLICANT. 


Lunatic's  Age    -  -  -  - 

Religion  -  .  .  . 

Place  of  Birth   -  -  - 

Place  of  Abode  .  -  -  - 

Occupation  or  Trade  -  -  - 

Whether  Single  or  Married,  and  if  a 
Female,  whether  she  has  had  Child- 
ren     ----- 

Whether  any  near  Relative  has  been  ^ 
Insane  -  -  -  -  ) 

How  long  ill,  and  if  violent       -  - 

Dated day  of IS 

Signed 


It  is  requested  that  a  person  will  accompany  the  Patient  to  the  Asy- 
lum, who  will  be  able  to  give  the  best  information  respecting  the  disease, 
former  mode  of  life,  habits,  propensities,  etc. — and  that  such  Patient  be 
furnished  with  a  good  strong  suit  of  clothes,  a  change  of  linen,  and  other 
articles. 


CERTIFICATE  REQUIRED  UNDER  AMENDED  XXVI.  PRIVY 
COUNCIL  RULE  FOR  CHANGING  A  NON-PAYING  PATIENT 
INTO  A  PAYING  ONE. 


We  hereby  certify  that  we  are  personally  acquainted  with  the  circum- 
stances of and friends,  and  that  to  the  best  of  our  know- 
ledge and  belief ^is  unable,  and     friends  are  unable  or 

unwilling,  to  pay  for care  and  maintenance  in  a  private  Lunatic 

Asylum. 

Magistrate 

Clergyman 


Dated 


To  the  Governors, District  Asylum. 

The  speediest  method  of  admission  into  the  district  asylums 
in  Ireland  is  to  have  the  patient  certified  as  a  "  dangerous  " 
lunatic  or  idiot,  that  is,  that  he  is  a  lunatic  or  idiot  who  apparently 
has  the  purpose  of  committing  an  indictable  crime  {vide  supra 


314         LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

"Committal  Warrant,  etc.").  The  information  is  sworn  by  a 
constable  or  constables  before  two  magistrates  (sitting  together) 
who  see  and  examine  the  patient  and  call  to  their  assistance 
a  dispensary  medical  officer. 

Attention  has  been  called  ("  Med.  Press  and  Circ,"  Sept.  9th, 
1891)  to  the  fact  that  of  3,095  persons  certified  insane  in  Ireland 
during  the  last  official  year,  2,165,  or  70  per  cent.,  were  certified 
as  "  dangerous  lunatics,"  whereas  in  Scotland  only  five  persons, 
or  0'2  per  cent,  of  those  admitted  during  the  year  belonged  to  the 
same  category.  The  friends  of  "dangerous  lunatics  "  are  exempt 
from  payment  in  Ireland. 

It  is  to  be  inferred  from  the  last  (40th)  Keport  of  the  In- 
spectors of  Lunatics  that  there  are  now  no  "  single  patients  "  in 
Ireland,  and  that  insane  paupers  are  not  "  boarded  out  "  as  in 
Scotland  and  England.  National  institutions  (similar  to  the 
Royal  Albert  and  Earlswood  in  England,  and  Larbert  and 
Baldovan  in  Scotland)  for  the  training  and  education  of  idiots  and 
imbeciles,  are  much  required. 

CERTIFICATION  OF  THE  INSANE  IN  THE  STATE 
OF  NEW  YORK. 

(Chapter  126,  Lsiws  of  1890.) 

Sect.  1. — In  accordance  mth  the  provisions  of  this  section  the 
board  for  the  establishment  of  State  insane  asylum  districts  and 
other  purposes,  has  divided  the  State  into  State  insane  asylum 
districts. 

Sect.  5. — Each  of  the  State  asylums  for  the  insane  shall  receive 
patients,  whether  in  an  acute  or  chronic  condition  of  insanity, 
from  the  district  in  which  the  asylum  is  situated. 

Sect.  9. — In  case  any  insane  person,  his  relatives,  guardians 
or  friends  may  desire  that  he  become  an  inmate  of  any  State 
asylum  situated  beyond  the  limits  of  the  district  where  he  resides, 
and  there  be  sufficient  accommodation  there  to  receive  him,  he  may 
be  received  there  in  the  discretion  of  the  chairman  of  the  State 
Commission  in  Lunacy  and  the  superintendent  of  such  asylum. 
Any  expenses  of  removal,  in  such  case,  must  be  borne  by  said 
insane  person's  guardians,  relatives,  or  friends,  as  the  case  may  be. 

Commitment  of  Patients. 
(Chapter  446,  Laws  of  1874.) 

Sect.  1. — No  person  shall  be  committed  to  or  confined  as  a 
patient  in  any  asylum,  public  or  private,  or  in  any  institution, 
home  or  retreat  for  the  care  and  treatment  of  the  insane,  except 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  315 

upon  the  certificate  of  two  physicians,  under  oaths,  setting  forth 
the  insanity  of  such  person.  But  no  person  shall  be  held  in  con- 
finement in  any  such  asylum  for  more  than  five  days,  unless 
Avithin  that  time  such  certificate  be  approved  by  a  judge  or  justice 
of  court  of  record  of  the  county  or  district  in  which  the  alleged 
lunatic  resides,  and  said  judge  or  justice  may  institute  inquiry 
and  take  proofs  as  to  any  alleged  lunacy  before  approving  or 
disapproving  of  such  certificate,  and  said  judge  or  justice  may,  in 
his  discretion,  call  a  jury  in  each  case  to  determine  the  question 
of  lunacy. 

Sect.  2. — It  shall  not  be  lawful  for  any  physician  to  certify  to 
the  insanity  of  any  person  for  the  purpose  of  securing  his  com- 
mitment to  an  asylum,  unless  said  physician  be  of  reputable 
character,  a  graduate  of  some  incorporated  medical  college,  a 
permanent  resident  of  the  State,  and  shall  have  been  in  the 
actual  practice  of  his  profession  for  at  least  three  years.  And 
such  qualifications  shall  be  certified  to  by  a  judge  of  any  court  of 
record.  No  certificate  of  insanity  shall  be  made  except  after  a 
personal  examination  of  the  party  alleged  to  be  insane,  and 
according  to  forms  prescribed  by  the  State  Commission  in  Lunacy 
(these  blank  forms  may  be  obtained  free  upon  application  to  the 
State  Commission  in  Lunacy,  county  clerks,  superintendents  of 
the  poor,  and  the  superintendents  of  asylums  or  hospitals  for  the 
insane),  and  every  such  certificate  shall  bear  date  of  not  more 
than  ten  days  prior  to  such  commitment. 

Sect.  3. — It  shall  not  be  lawful  for  any  physician  to  certify  to 
the  insanity  of  any  person  for  the  purpose  of  committing  him  to 
an  asylum  of  which  the  said  physician  is  either  the  superinten- 
dent, proprietor,  an  officer,  or  a  regular  professional  attendant 
therein. 

{Chapter  283,  Laws  of  1889,  as  amended  hi/  C/uqjter  273,  Laws  of 
1890.) 

Sect.  7. —  ^''  *'"'  "'■'  '^''  One  year  after  the  date  of  the  passage 
of  this  act  (May  14,  1889),  it  shall  not  be  lawful  for  any  medical 
examiner  in  lunacy  to  make  a  certificate  of  insanity  for  the 
purpose  of  committing  any  person  to  custody  unless  a  certified 
copy  of  his  certificate  has  been  so  filed  and  its  receipt  in  the  office 
of  the  Commission  (State  Commission  in  Lunacy),  as  above  pro- 
vided has  been  acknowledged. 

In  addition  to  the  medical  certificate  of  two  physicians  sworn 
to  and  approved  by  a  judge  in  the  county  in  which  the  patient 
resides,  there  must  be  presented  at  the  time  of  admission  of 
a  patient  either  an  order  from  the  superintendent  of  the  poor,  or 
the  county  judge,  or  a  bond  (in  case  of  private  patient)  guaran- 
teeing the  amount  charged  for  care  and  treatment. 


316       legal  regulations  and  forensic  psychiatry, 

Admission  of  Private  Patients  to  the  State  Hospital 
FOR  THE  Insane. 

On  and  after  October  1,  1890,  there  shall  be  no  distinction 
allowed  between  private  and  public  patients  in  respect  to  the 
scale  or  care  and  accommodations  furnished  them. 

On  and  after  October  1, 1890,  no  private  patient  will  be  admitted 
to  any  State  hospital  except  in  strict  accordance  with  the  statute  : 
"Whenever  there  are  vacancies  in  the  asylum  (State  Hospital) 
there  may  be  received  such  recent  cases  as  may  seek  admission 
under  peculiar^  afflictive  circumstances,  or  which  in  the  superin- 
tendent's opinion  promise  speedy  recovery  and  upon  an  order 
granted  by  the  State  Commission  in  Lunacy  upon  an  application 
in  A^o-iting,  addressed  to  the  Commission,  of  a  near  relative, 
guardian  or  committee  of  the  patient.  (Dr.  C.  W.  Pilgrim, 
"  Report  of  Trustees  of  Willard  State  Hospital,"  1890.) 

CERTIFICATION  OF  THE  INSANE  IN 

THE   STATES    OF    CONNECTICUT,    PENNSYLVANIA, 

MASSACHUSETTS,  AND  ILLINOIS. 

In  Connecticut  there  are  required  for  the  admission  of  a  private  ■ 
patient  into  the  hospital  for  the  insane  only  a  request  signed  by  a 
guardian,  near  relative,  or  friend,  and  one  medical  certificate 
running  thus  : — "  I  hereby  certify  that  I  have,  within  one  week 
of  this  date,  made  personal  examination  of  A.B.,  of  CD.,  and 
believe  him  to  be  insane."  This  is  subscribed  and  sworn  to  by 
the  physician  before  an  officer  authorised  to  administer  oaths,  who 
certifies  to  the  respectability  of  the  physician  and  the  genuineness 
of  the  signature. 

In  Pennsylvania,  in  ordinary  cases  it  is  necessary  that  the 
medical  certificate  should  be  signed  by  at  least  two  physicians 
actually  in  practice  five  years,  who  shall  certify  that  they  have 
separately  examined  the  patient,  and  believe  him  to  be  insane 
and  requiring  the  care  of  an  asylum.  They  must  not  be  related 
by  blood  or  marriage  to  the  patient,  or  connected  medically  or 
otherwise  Avith  the  institution.  This  certificate  must  be  made 
Avithin  one  week  of  the  examination  of  the  patient,  and  within 
two  weeks  of  his  admission.  Further,  it  must  be  sworn  to  or 
affirmed  before  a  judge  or  a  magistrate,  who  must  certify  the 
genuineness  of  the  signature,  and  the  standing  and  good  repute  of 
the  signers.  It  is  not,  however,  necessary  that  the  judge  or 
magistrate  should  examine  the  patient,  or  express  any  opinion  in 
regard  to  his  insanity.  The  order  and  statement  are  signed  by 
the  person  at  whose  instance  the  patient  is  received. 

The  law  of  Pennsylvania  allows  persons  to  place  themselves 


LEGAL   REGULATIONS   AND   EORENSIO   PSYCHIATRY.  317 

voluntarily  in  an  asylum  for  a  period  not  exceeding  seven  d'dya, 
on  signing  an  agreement  giving  authority  to  detain  them,  which 
may  be  renewed  from  time  to  time  for  the  same  period. 

In  Massachusetts  there  are  required  the  certificates  of  two 
physicians  (the  facts  upon  which  their  opinions  are  founded 
being  specified),  and  an  order  signed  by  a  judge  certifying  that 
he  finds  that  the  person  committed  is  insane,  and  fit  for  treatment 
in  an  asylum.  If  the  judge  thinks  it  undesirable  to  see  the 
patient,  he  may  certify  to  that  effect  and  still  commit  him.  If  he 
is  in  doubt  he  may  summon  a  jur}''  of  six  to  his  aid. 

An  urgent  case  may  be  received  by  the  superintendent  and 
detained  for  five  days  on  an  emergency  certificate.  This  is 
signed  by  two  physicians  who  certify  that  the  patient  is  labouring 
under  violent  and  dangerous  insanity,  and  it  is  accompanied  by 
an  application  for  admission  from  the  Mayor  or  one  of  the 
Aldermen  of  the  place  in  which  the  patient  resides. 

In  Illinois  the  alleged  lunatic  must  be  tried  by  a  county  court 
judge  and  di,  jury  of  six.  The  patient  is  examined  by  a  physician 
employed  by  the  Court.  This  official  states  to  the  Court  and  the 
jury  the  result  of  his  medical  examination.  Evidence  is  also 
■given  by  the  relatives  and  friends  of  the  person  supposed  to  bt 
insane.  Finally  the  jurors  retire  to  consider  their  verdict. 
("  The  Insane  in  the  United  StPvtes,"  by  D.  Hack  Tuke,  "Jour. 
Ment.  Science,"  April,  1885). 

TESTAMENTAEY  CAPACITY  OF  THE  INSANE. 

In  England  the  law  is  much  more  influenced  by  the  will  itself 
than  by  any  evidence  as  to  the  mental  state  of  its  maker.  If 
known  to  be  in  accordance  with  his  wishes  when  sane,  it  will 
probably  be  ruled  valid.  If  made  during  a  period  of  sanity  by  a 
lunatic,  it  will  probably  be  ruled  valid,  if  consistent.  Persons 
sufFei-ing  from  acute  forms  of  insanity  (mania  and  acute  melan- 
cholia) ;  from  weak-mindedness  either  congenital  or  the  result  of 
apoplexy,  epilepsy,  acute  mental  disease,  or  senility ;  or  from 
suspicious  monomania,  are  very  liable  to  have  their  wills  upset. 

In  acute  forms  and  sometimes  in  weak-mindedness,  the  failure 
arises  from  actual  incapacity.  In  most  cases  of  weak-mindedness, 
the  cause  of  failure  is  the  testator's  susceptibility  to  undue  influence. 
Persons  suffering  from  weak-mindedness  consecutive  to  acute 
insanity,  may  dislike  their  relatives  or  refuse  to  forgive  them  for 
having  put  them  in  an  asylum,  or  they  may  display  emotional 
instability,  leaving  their  property  to  some  institution  for  which 
they  had  no  regard  before  the  attack  of  insanity. 

In  senile  weak-mindedness  the  testator  will  be  frequently  found 
to    be    querulous,    exacting,    exhibiting    defective,    often    very 


318  LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

defective  memory,  and  so  forgetting  heirs-at-law,  etc.  The  sexual 
passions  may  also  be  abnormally  strong  in  senility,  and,  for  this 
reason,  as  well  as  in  consequence  of  the  general  mental  weakness, 
such  testators  may  be  the  subjects  of  undue  influence. 

In  weak-mindedness  following  apoplexy,  the  ^dll  may  be  dis- 
puted because  the  testator  is  aphasic  although  perfect  testa- 
mentary capacity  may  exist  \\'ith  aphasia  ;  but  when  amnesia  and 
aphasia  are  combined,  the  patient  may  be  unable  to  make  a  will 
or  may  be  too  readily  influenced.  If  after  apoplexy  the  memory 
is  retained,  and  there  is  no  change  in  the  patient  which  would 
influence  his  opinions  of  his  near  relatives,  he  should  be  allowed 
to  make  a  will. 

Before  outbreaks  of  insanity  the  patient  though  apparently 
sane,  may  suffer  from  a  moral  perversion,  caiising  him  to  suspect 
and  dislike  his  relatives  and  make  a  will  to  their  disadvantage  ; 
this  is  especially  liable  to  occur  when  there  have  been  previous 
attacks  of  insanity  followed  by  confinement  in  an  asylum. 

The  onset  of  melancholia  may  be  associated  with  the  revocation 
or  alteration  of  a  will,  the  testator  leaving  his  property  to  charities 
or  religious  bodies  to  atone  for  his  STipposed  past  misdeeds. 

The  suspicious  monomaniac  may  destroy  all  wills,  or  make  a 
will  in  favour  of  a  stranger  or  of  charitable  institutions.  (Savage, 
"  Insanity  and  allied  Xeuroses,"  page  473,  et  seq.).  Persons 
suffering  from  any  form  of  delusion  as  to  the  amount  of  property 
possessed  by  them,  whether  the  delusion  is  in  excess  of  the 
reality  or  the  opposite  (ambitious  monomania,  general  paralysis, 
melancholia),  Avould  be  likely  to  have  their  wills  upset. 

AVhen  a  medical  man  is  examining  a  patient  as  to  his  testa- 
mentary capacity  Clouston  (oj).  cif.)  recommends  that  he  should 
ascertain  :  (1,)  \Vhether  the  patient  is  free  from  the  influence  of 
drink  or  drugs  ;  (2,)  Whether  he  understands  the  nature  of  the 
act  he  is  about  to  perform,  and  the  effect  of  the  document ; 
(3,)  Whether  the  disposition  of  the  property  is  a  natural  one  or 
the  result  of  delusions  or  mental  weakness  ;  (4,)  Whether  there  is 
mental  facility  from  bodily  weakness  or  other  cause,  undue 
influence  being  exerted  from  %vithout.  Under  these  circum- 
stances it  is  advantageous,  in  order  to  ascertain  the  truth,  to  be 
alone  with  the  patient ;  (5,)  Whether  the  intending  testator 
is  able  to  go  over  the  particulars  of  the  proposed  disposition  of 
his  property  without  help,  and  repeat  his  statement  correctly  after 
an  intervarof,  say,  a  quarter  of  an  hour  :  (6,)  Whether  he  knows 
in  a  general  way  the  amount  of  the  property  he  has  to  bequeath. 

Clouston  {loc.  cit.)  ad^dses  "not  to  let  a  good  motive  make  us 
sanction  a  bad  will,  however  natural  its  proA-isions  may  be,  how- 
ever much  trouble  or  expense  it  may  save." 


LEGAL  REGULATIONS  AND  FORENSIC  PSYCHIATRY.    319 

According  to  Taylor  ("  Medical  Jurisprudence  ")  the  validity 
of  a  will  depends  not  so  mucli  upon  the  sanity  or  insanity  of  the 
testator  as  upon  his  competency  or  incompetency  to  make  a  will. 
The  best  test  of  comj^etency  is  that  the  testator  should  know,  at 
the  time  of  signing  the  will,  the  nature  and  amount  of  his 
property  and  the  just  claims  of  his  near  relations.  Taylor 
reminds  the  medical  man  that  Avhen  he  acts  as  a  witness  to  a  will, 
he  practically  testifies  to  the  competency  of  the  testator  to  make 
it.  The  same  author  quotes  cases  which  show  that  a  person 
may  be  placed  under  interdiction  or  even  confined  in  a  lunatic 
asylum,  and  yet  be  competent  to  make  a  will. 

Maudsley  remarks  ("  Eesponsibility  in  Mental  Disease")  that 
formerly,  if  an  insane  testator  made  a  natm^al  disposition  of  his 
property,  a  lucid  interval  at  the  time  of  making  the  Avill  was 
presumed.  It  was  at  one  time  held  that  delusion  voids  a  will. 
This  was  at  first  rejected  in  Xew  Hampshire,  U.S.,  and  after- 
wards in  the  Court  of  Queen's  Bench.  Maudsley  says  it  is 
necessary  to  wait  for  future  decisions  to  learn  whether  the 
principle  laid  down  in  the  latter  case  (Banks  t\  Goodfellow)  is  to 
govern  the  nuiking  of  contracts  by  partially  insane  persons,  or 
whether  such  contracts  are  to  be  voided  in  accordance  with  the 
old  rule  that  the  law  voids  eA^ery  act  of  the  lunatic,  although  the 
insanit}^  may  be  extremely  circumscribed,  and  although  the  act 
to  be  voided  has  been  in  no  way  influenced  by  the  insanity. 

THE  EVIDENCE  OF  THE  INSANE. 

The  two  points  to  be  primarily  considered  in  estimating  the 
value  of  the  evidence  of  insane  persons  are  : — 1st,  Is  the  patient 
in  such  a  condition  mentally  as  to  know  that  he  ought  to  speak 
the  ti^uth  to  the  best  of  his  ability  1  and  2nd,  Is  he  able  to  report 
the  facts?  ("Journ.  Ment.  Sci.,"  January  1,  1891,  page  110). 
In  the  case  of  Regina  v.  Hill  the  attendant  (Hill)  was  found  guilty 
of  manslaughter  mainly  on  the  evidence  of  a  lunatic  who  laboured 
under  the  delusion  that  he  had  spirits  in  his  head.  The  case  was 
argued  before  four  judges,  who  hold  unanimously  that  this 
lunatic's  evidence  was  properly  admitted.  In  citing  authorities 
two  cases  were  quoted  in  which  the  evidence  of  persons  partially 
or  wholly  insane  was  admitted.  The  witness  may  be  examined 
as  to  his  mental  state,  and  the  evidence  of  witnesses  may  be 
adduced  as  to  his  actual  state  of  sanity  or  insanity. 

Campbell  ("  Complaints  by  Insane  Patients,"  "  Journ.  Ment. 
Sci.,"  October,  1881,)  called  attention  to  a  case  where  an  attend- 
ant was  fined  in  a  Scotch  Sheriff's  Court  for  assaulting  a  patient 
on  the  sole  evidence  of  the  patient,  who  was  stated  to  be  labour- 


320  LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

ing  under  delusions.  The  medical  evidence  was  to  the  effect 
that  the  patient's  delusions  had  no  reference  to  his  injuries,  and 
that  his  statement  as  to  how  he  received  the  latter,  could  be 
implicitly  relied  on.  In  a  recent  case  an  attendant  (Hays),  who 
had  been  discharged  after  the  inquest  on  a  patient  formerly 
under  his  care,  took  an  action  for  "WTongful  dismissal  against  the 
Board  of  Governors  of  the  Richmond  Asylum.  The  Recorder  of 
Dublin  held  the  evidence  of  two  lunatics  (who  testified  as  to  the 
violence  of  Hays  toAvards  the  deceased)  to  be  practical^ 
A'alueless,  and  directed  the  jury  to  find  a  verdict  for  the  plaintiff' 
(Hays).  Yet  the  Recorder  said  the  witnesses  had  given  their 
evidence  admirably  and  that  "  he  had  never  heard  better 
witnesses."  On  appeal,  this  judgment  was  quashed  by  Justice 
Holmes  on  the  gTound  that  the  Governors  were  justified  in  dis- 
missing Hays  or  any  other  servant,  "^Wthout  giving  any  reasons 
whatever.  He,  therefore,  did  not  consider  it  necessary  to  call 
the  patients  as  ^sWtnesses.  In  respect  to  the  evidence  of  a  person 
of  unsound  mind  he  said,  "  First  I  must  be  satisfied  that  the 
person  understands  the  nature  of  an  oath,  and  next,  that  he 
understands  and  appreciates  the  evidence  he  is  giving."  ("  Journ. 
Ment.  Science,"  loc.  cit.). 

LEGAL    TESTS    OF    INSANITY    AND    LEGAL 
RESPONSIBILITY  OF  THE  INSANE. 

"  A  testatm'  is  considered  to  be  sane  if  he  is  '  of  sound  mind, 
memory,  and  understanding.'  In  huiaci/  inquisitions  the  test  is  : 
'  Is  the  patient  capable  of  managing  himself  and  his  affairs  ? ' 
In  criminal  cases  the  legal  test  of  insanity  is  the  knowledge  of 
right  and  wrong  ;  that  is  to  say,  a  criminal  is  considered  to  have 
been  sane  when  he  committed  his  crime  if  '  he  then  knew  the 
nature  and  quality  of  the  act  and  that  it  was  TATong.' "  (Mercier, 
"  Sanity  and  Insanity,"  pp.  98,  99). 

Vide  supra  "  Testamentary  Capacit}^  of  the  Insane  "  re  first 
test.  With  regard  to  the  second  test,  the  inquisition,  so  far  as 
it  finds  the  lunatic  incapable  of  managing  himself,  may  be  super- 
seded, and  any  order  for  commitment  varied  or  rescinded. 

The  last  test  is  manifestly  intended  to  be  that  of  the  legal 
responsibility  of  insane,  or  alleged  insane  persons  who  have 
committed  crimes ;  but  the  plea  of  imcontrollable  impulse  may 
be  raised  even  after  the  accused  person  has  been  found  responsible 
by  the  above  test,  in  which  event  the  patient's  anamnesia  ought 
to  be  useful 

Maudsley  observes  {op.  cit.)  that  by  the  judgment  of  the  Coiu't 
of  Queen's  Bench  in  the  case  of  Banks  r.  Goodfellow,  the  law 


LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY.  321 

relating  to  testamentary  capacity  is  made  to  agree  with  that  re- 
lating to  criminal  responsibility  so  far  as  this. — That  a  partially 
insane  person  is  competent  to  make  a  will  or  commit  a  crime  : 
not  being  declared  incapable  in  the  one  case,  nor  exempted  from 
punishment  in  the  other,  except  when  the  act  can  be  shown  to  be 
the  offspring  of  the  insanity.  But  they  differ  in  these  points : 
(1,)  That  while  an  insane  delusion  will  invalidate  a  will  springing 
from  it,  an  insane  delusion  will  not  always  invalidate  a  criminal 
offence  arising  from  it ;  (2,)  That  while  the  disordered  feelings  in 
insanity  have  due  weight  given  to  them  in  will  cases,  they  receive 
no  consideration  in  criminal  trials ;  and  (3,)  That  while  no 
special  test  of  civil  capacity  is  enunciated  as  a  legal  principle,  the 
whole  case  being  decided  upon  its  merits  by  the  jury,  a  special 
test  of  responsibility  is  proclaimed  as  a  legal  principle  in 
criminal  cases. 

The  "  right  and  wrong  "  test  is  the  one  applied  by  the  majority 
of  legal  authorities,  but  it  is  not  the  only  one  that  is  or  has  been  used. 
According  to  Clouston  ("  Ment.  Dis."  1st.  Ed.  p.  617)  Judge  Tracey 
held  that  a  criminal  should  be  punished  unless  he  was  as  irrespon- 
sible as  a  wild  beast ;  Lord  Denman  made  the  presence  or  absence 
of  insane  delusion  the  test ;  Lord  Moncrieff,  "  the  man's  habit 
and  repute  as  to  sanity  among  his  fellow-men  who  knew  him 
well ; "  and  lastly,  Justice  Stephen's  new  criminal  code  "  proposes 
to  make  the  man's  power  of  controlling  his  actions  the  test,"  he 
being  also  guilty  if  the  mental  disease  causing  loss  of  self-control 
has  been  produced  by  his  own  default. 

"  The  law  now  recognises  only  one  test  of  lunacy,  viz..  Was  the 
person  whose  act  is  in  question  able  to  understand  its  nature,  and 
to  pass  a  fairly  rational  judgment  of  its  consequences  to  himself 
and  others,  and  was  he  a  free  agent  so  far  as  that  act  was 
concerned  r'  ("  Journ.  Ment.  Sci.,"  July  1891,  jj.  422). 

The  above  test  practically  contains  the  propositions  of  the  new 
Criminal  Code  regarding  responsibility.  Taylor  (op.  cit.)  points 
out  that  an  act  may  be  an  offence,  although  the  mind  of  the 
person  who  does  it  is  affected  by  disease,  or  is  deficient  in  power, 
if  such  disease  or  deficiency  does  not  produce  one  or  other  of  the 
effects  mentioned  in  these  propositions.  In  order  to  justify  legal 
responsibility  it  is  not  sufficient  to  prove  insanity ;  it  must  be 
proved  that  the  insanity  has  reached  a  certain  degree.  Voluntarj^ 
drunkenness  is  excepted  from  these  provisions.  A  criminal  act 
implies  the  existence  of  intention,  will,  and  malice.  The  presence 
of  delusion  does  not  necessarily  constitute  irresponsibility,  nor 
does  the  total  absence  of  delusion  entail  responsibility.  The 
surrounding  circumstances  must  be  taken  into  account. 

Guy    ("The  Factors  of  the  Unsound  Mind  and  the  Plea  of 

21 


322         LEGAL   REGULATIONS   AND   FORENSIC   PSYCHIATRY. 

Insanity,"  p.  222)  gives  as  the  four  principal  sources  of  delusion 
leading  to  homicidal  acts  : — Religious  excitement  or  despondency: 
jealousy  ;  domestic  anxiety  exaggerated  into  fear  of  starvation  : 
and  discontent  transformed  into  an  insane  belief  in  persecution. 

The  forms  of  insanity  in  which  crimes  are  committed  are  : — 
Impulsive  insanity,  moral  insanity,  periodical  insanity,  circular 
insanity,  mania,  epileptic  insanitj^,  alcoholic  insanity,  traumatic 
insanity,  puerperal  insanity,  delusional  melancholia,  suicidal  (and 
homicidal)  melancholia,  paranoia,  incipient  general  paralysis 
(shop  lifting,  etc.),  dementia,  imbecility  (see  Chap.  III).  Insanity 
may  be  feigned  (see  "  Diagnosis  "),  and  a  patient  suffering  from 
one  form  of  mental  disease  may  simulate  another.  In  impulsive 
cases  and  in  cases  of  insane  temperament  or  diathesis  Avithout 
certifiable  insanity,  the  patient's  anamnesia,  including  both  his 
family  and  personal  history,  should  be  carefully  investigated. 


323 


GENERAL    INDEX. 


Albers,  p.  84;  Alexander, 
264;  AUbutt  (Clifford),  36, 
40;  Arndt,  61;  Archbold, 
2,  286 

Abdominal  disorders    . . 

insanity  from  (etiology) 

Aberration,    mental,    grouping 
of  forms  of 

—  partial  emotional 

—  —  —  (etiology) 

(prognosis) 

(treatment) 

Ability  to  write,  loss  of 
Abnormalities  of  speech 
Abruptness  of  outbreak 
Absence  of  sexual  desire 

two  or  more  senses 

Absent-mindedness 
Absinthe,  insanity  from 
Abulia 

—  congenital 
Acquired  mental  weakness 
Action  and  speech,  monotony  of 

—  and  thought,  want  of  con- 

tinuity in 

—  .^  want  of  force  in . . 

—  or  speech  limited    . . 
Actions,  childishness  in 

—  improvidence  of 

—  motiveless 
Active  melancholia 
Activity,  unusual  and  useless 
Acts  andspeech,  inconsistencies 

in  . . 


49 

137 

131 

105 

148 

184 

266 

33 

43 

11 

216 

41 

11 

126 

11 

157 

132 

34 

16 
28 
33 
15 
30 
34 
97 
11 

31 


Acute  delirium  (prognosis) 
■ —  —  (treatment) 
—  dementia 

(etiology) . . 

(prognosis) 


and  words,  paying  attention  to  36 


— to  own 

.     48 

—  extraordinary 

.     11 

—  impulsive 

.     30 

—  monotonous  . . 

.     11 

Acute  alcoholic  insanity 

.   120 

(prognosis)     . . 

.   187 

—  confusional  insanity 

.     56 

—  delirium 

.     60 

—  —  (diagnosis) 

.   165 

(etiology) 

.   138 

(pathology) 

.   194 

PAGE 
.     175 

.  263 
.  117 
.  144 
.  186 
epileptic  insanity  (diagnosis)  165 

—  mania  . .  . .  . .     90 

(diagnosis)  . .  . .   163 

Acuteness    of    the    senses,    to 

investigate  the  . .  vi,  152 
Admission  into  private  asylums 

(Ireland)  ..  ..   301 

—  —  asjdums   . .  . .  . .   153 

—  of  private  patients  to  hos- 

pital (New  York  State)  816 
Adolescent  insanity  . .  . .  49 
(etiology) 137 

—  —  (prognosis)           . .          . .  173 

(treatment)         . .          . .  263 

Affection  natural,  loss  of         . .  35 

Affections  of  the  will  . .  . .  48 
Affective  sensibility,  perverted, 

etc 11 

—  sentiments    . .  . .  . .     79 

Ageustia  (or  Ageusia)    ..  ..     11 

Aggressiveness   . .  . .  . .     11 

Agitated  melancholia  . .  . .     97 

Agitation,  excessive      . .  . .     11 

Agoraphobia       . .  29,  105,  158 

—  (prognosis)     . .  . .  . .   184 

Alcohol  and   drugs,    increased 

reaction  to  . .  . .     39 

Alcoholic  and  other  intoxication 

(diagnosis)  . .  . .   148 

—  dementia       . .  . .  . .   126 

—  excesses,  tendency  to         . .     12 

—  insanity         . .  . .  . .   120 

chronic     . .  . .  . .   123 

Alcoholic  insanity  (pathology)  202 
(prognosis)  . .  . .   187 

—  paralysis       . .         . .         . .   160 

—  pseudo-general  paralysis  . .  125 
Alienists'  classification  . .  3 
Alterations  in  the  blood  14,  79 

—  of  sentiments  . .  . .  41 
Ambitious  delusions     . .  . .   156 


324 


GENERAL   INDEX. 


PAGE 

Amenomania      . .         . .  106,  158 

—  (etiology)       143 

—  (prognosis)     . .         . .  . .   184 

Amenorrhoea       . .          . .  . .     12 

Amenorrliceal insanity. .  ..   131 

(diagnosis)          . .  . .   163 

(etiology)             . .  . .   145 

(prognosis)           . .  . .   188 

Amnesia  . .          . .          . .  . .     12 

Amylene  hydrate  in  insomnia     245 

Ansemia  . .          . .         . .  . .     12 

Anaemic  insanity           . .  . .     50 

(diagnosis)           . .  . .   157 

(etiology)             . .  . .  137 

(prognosis)           . .  . .   178 

Angesthesia          . .          . .  . .     12 

—  cutaneous      . .          . .  . .     16 

Anatomy,  pathological . .  . .   189 

Anergic  stupor    . .          . .  117,  167 

(etiology)..          ..  ..   144 

(prognosis)           . .  . .   186 

Animals,   devils,   etc.,  seen  by 

patient     . .         . .  . .   164 

Aim.oyance  at  trifles     . .  . .     12 

Anorexia  . .  . .  . .        12,  160 

—  and  sitophobia  215 

Anosmia  . .  . .         . .         . .     12 

Answering     of     questions     by 

patient     . .  . .  . .   154 

Anthropophobia  . .  . .   105 

Antipathy  to  friends  and  rela- 
tions        . .  . .  . .     39 

Anxiety    . .         . .         . .  . .     12 

Apathy     . .  . .  . .  . .     12 

Aphasia    . .  . .  . .  . .     13 

—  (diagnosis)     . .         . .  . .   149 

Apoplectiform  attacks  . .     13 

Apoplexy  . .  . .  . .  . .     54 

Apprehensiveness  . .  . .     13 

Arachnoid,  the  (macroscopical 

morbid  anatomy)  . .   189 

Arcus  senilis       . .         . .         . .     13 

Arteries  atheromatous . .  ..     13 

Assertions,  false  and  malevolent    23 
Asthma,  insanity  of     . .  vi,  59,  165 
Astraphobia        ..         ..         ..  106 

Asylum,  district  rules  for  (Ire- 
land)         309 

— •  examination  of  patient  in . .  279 

—  private,       admission      into 

(Ireland) 301 

—  removal  of  patientto  another  287 

—  treatment      . .  . .         . .   259 

Asylums,  admission  into         . .   158 

—  forms  of  insanity  met  v?ith 

at .170 


PiGE 

Asylums  pauper  . .  . .   259 

—  private  . .  . .  . .   261 

Ataxia 18,  78 

Atony       ..         ..         ..  ..13 

Atrophy,  optic  nerve  changes, 

etc.           . .         . .         . .  36 

Attacks,  apoplectiform            . .  13 

—  epileptiform  . .  . .  21 
Attendant,  medical,  duties  of  287 
Attention,  defective      . .          . .  13 

morbid  anatomy  of       . .  213 

Attitude,  immobile       . .          . .  13 

—  insinuating  . .          . .          . .  13 

—  listless            . .         . .          . .  13 

—  suggestive  of  auditory  hal- 

lucinations . .  . .     13 

—  suggestive   of   delusions    of 

grandeur              . .          . .  13 
Auditor}'  disturbances,  morbid 

anatomy  of         . .         . .  204 

—  hallucinations  . .  . .  25 
Automatic  ideas  and  words  . .  14 
Aversion  to  movement  . .  35 
Awkwardness  in  manipulations  33 

Baillaegee,  p.  51 ;  Bain, 
218  ;  Ball,  5,  24,  70,  177  ; 
Bastian,  228  ;  Batty  Tuke, 
136,  191,  219;  Bell,  60; 
Bertheir,  110 ;  Bischofi, 
193;  Blandford,  100,  101, 
126,  127,  142,  180,  188; 
Boeck,    216;    Bra,    5,   15, 

25.  26,  50,  51,  52,  60,  61, 
62,  63,  64,  67,  68,  69,  71, 

82,  87,  98,  94,  97,  105, 
118,  115, 116, 118,  123,  124, 
126,  129, 138,  141, 144, 177, 
178,  185,  188,  194, 197, 198, 
200,  216  ;  Briand,  194, 
195  ;  Bricquet,  198  ;  Broad- 
bent,  38,  39;  Browne 
(Crichton),  214;  Bucknill 
and  Tuke,  1,  3,  17,  24,  25,    - 

26,  49,  50,  53,  54,  58,  59,  65, 

83,  84,  85,  86,  89,  106,  110, 
112,  135,  136, 146,  169,  172, 
174,  176,  178, 179,  181, 184, 
192,  216,  261 

Babbling  and  chattering  . .  14 

Back,  weakness  in        . .  . .  14 

Bacteria  in  blood           . .  . .  79 

Bang,  insanity  from  (diagnosis)  165 
Barometric  and  seasonal  con- 
ditions     . .          . .  . .  14 

Bed,  refusal  to  leave     . .  . .  14 


GENERAL  INDEX, 


325 


PAGE 

Bed  sores  . .  . .  . .     14 

Being  controlled,  sense  of,  etc.      16 
Biliousness         . .         . .  . .     14 

Birth,  oddness  and  peculiarity 

from         . .         . .  . .     36 

Bladder,  lesions  of        . .  . .   217 

Blindness  . .         . .  . .     14 

Bl5dsinn,  terminaler  . .  . .     65 

Blood,  alterations  in    . .  ,79 

—  alteration  of  . .  . .     14 

—  lesions  of       . .         . .  .  .   217 

Boarders  voluntary       . .  . .   279 

Bodily  functions,  disturbance  of     14 

—  symmetry,  want  of  . .  . .  14 
Bones,  lesions  of  . .  . .  218 
Book,  form  of  medical  visitation  282 
Borax  in  epilepsy  . .  . .  264 
Brain,     degeneration    of     the 

cortical  cells  of  the  . .  238 

—  disease,  coarse         . .  . .  54 

—  hypochondriasis       . .  . .  95 

—  nutrition  of  the        . .  . .  237 

—  tumours         . .         . .  . .  55 

—  weight  of  in  insanity  . .  192 
Bra's  classification  . .  . .  5 
Bright's  disease,  insanity  of  . .  50 

(etiology)       . .  . .  137 

(prognosis)     . .  . .  173 

with  (diagnosis)  . .  163 

Bromides,  the  in  insanity  . .  263 

Bronchitis,  cyanosis  from  . .  59 

Brutishness         . .          . .  . .  14 

Bucknill  &  Tuke's  percentages 

of  frequency  of  forms  of 
insanity   . .  . .  . .   169 

Bulimia   . .  . .  . .  . .     14 

Calmeil,|3.71;  Campbell,  319; 
Charcot,  55,  193;  Charles, 
221 ;  Clifiord  AUbutt,  36, 40 ; 
Clouston,  5,  6,  15,  30,  40, 
44,  47,  49,  50,  52,  53,  54,  56, 
58,  64,  66,  80,  86,  87,  88, 
89,  90,  91,  92,  93,  96,  97, 
98,  99,  100,  104,  105,  108, 
111,  112,  113, 116,  117,  118, 
126,  127,  129,  130,131,  137, 
138, 144,  169, 173,  176,  181, 
188,  217,  297,  321;  Crichton- 
Browne,  214 

Cachexia 14,  79 

Calculation  by  patient . .  . .   155 

—  defective        . .         . .  . .     14 

Cannabis  indica  in  motor  ex- 
citement . .         . .   245 

insomnia  . .  . .   244 


PAGE 

Cannabis  indica,  insanity  from  127 

(diagnosis)          . .  165 

Cardiac  disease  . .          . .          . .  59 

Carnal    knowledge    of    female 

patient,  penalty  of        . .  287 

Cases  of  primary  insanities     . .  241 

—  for  private  care        . .          . .  257 
Catalepsy            . .          . .          . .  14 

—  causes  of  (etiology)             . .  137 
Cataleptic  insanity       . .          . .  50 

.  (etiology) 137 

(prognosis)           . .          . .  173 

Catamenia,  disorders  of           . .  14 

—  suppression  of           . .          . .  44 
Causes,  exciting,  of  insanity  . .  135 

—  of  catalepsy  (etiology)        . .  137 

chorea  (etiology)            . .  137 

hallucinations    . .          . .  239 

—  —  insanity   . .          . .          . .  137 

in  England  &  Wales  134 

Cell,  the,  in  its  relation  to  other 

cells  of  cerebrum,  etc.      221 
Central  ganglia,  cells  of  the   . .   221 
Cephalalgia        . .         . .  . .     14 

Cerebellum      and      cerebrum, 

connections  of    . .  . .   227 

—  cells  of  the 221 

—  effects  of  removal  of  . .   229 

—  in  animals,  children,  idiots, 

etc.  . .  . .       228,  230 

—  size  and  development  of    . .   233 

—  the    (macroscopical  morbid 

anatomy)  . .  . .   193 

—  theories  as  to  functions  of 

227,  233 
Cerebral  hemispheres,  weight  of  231 

—  causes  of  insomnia  . .  . .   226 

—  localisation    . .  . .         vi,  202 

—  meningitis  (diagnosis)       . .   148 

—  neurasthenia  . .  . .   102 

—  rheumatism  . .  . .   114 

—  substance       (macroscopical 

morbid  anatomy)  . .   190 

Cerebrum,  cells  of  the . .  . .   221 

—  effects  of  removal  of        216,  230 
Certificate   as    to    mechanical 

means  of  restraint     . .   285 

—  —  personal  interview         . .   281 

—  for  criminal  lunatics           . .   296 
dangerous  lunatic    (Ire- 
land)      308 

non-paying  patient  (Ire- 
land)      313 

paying  patients  (Ireland)  310 

—  blank  forms  of,  where  pur- 

chased     . .  . .      280,  290 


326 


GENERAL   INDEX. 


PAGE 

Certificate  medical  (Ireland)  . .  302 

persons  disqualified  from 

signing         . .          . .  278 
(Scotland)            . .          . .  299 

—  of  death  of  patient  . .          . .  290 

—  —  emergency  (Scotland)  . .  300 

—  —  medical         practitioner 

(England  &  Wales)  272 
magistrates,    etc.     (Ire- 
land)           ..          ..305 
Certification  of  insane  patients 

in  England  &  Wales  269 

— Ireland          . .          . .  301 

State  of  Connecticut  316 

Illinois           . .          . .  316 

— Massachusetts          . .  316 

— Pennsylvania           . .  316 

New  York      . .         . .  314 

Scotland         . .          . .  296 

Chancery  patients         . .          . .  290 

Change  in  disposition  . .          . .  19 

—  of  habits        . .            24,  156,  157 

—  of  mood         . .          . .          . .  34 

—  of  occupation           . .          . .  36 

—  of  residence  with  patient  . .  286 

—  of  temper       . .          . .          . .  45 

Changes  in  retina         . .          . .  40 

—  in  skm            . .          . .          . .  42 

— •  vascular         . .          . .          . .  47 

Character,  change  of     . .          . .  14 

—  mobility  of     . .          . .          . .  34 

Chattering  and  babbling         . .  14 

Child,  ruling  instincts  in  the  . .  238 

—  the,  in  its  perceptions,  etc.  221 
Childhood,  melancholia  in  . .  238 
Childishness  in  actions  . .  15 
Children,  delirium  of  young   . .  131 

(diagnosis)      . .       164,  165 

■  —  (prognosis)     ..  ..188 

—  inj  uring         . .          . .          . .  31 

Chloralamide  in  insomnia       . .  245 

Chloral  hydrate  in  insomnia  . .  243 

—  insanity  from  . .  . .  127 
Choreic  insanity            . .          . .  50 

(etiology)             . .         . .  137 

(pathology)          . .          . .  193 

(prognosis)           . .          . .  173 

—  ■ — ■  (treatment)         . .          . .  262 

—  movements    . .         . .          . .  15 

Chronic  alcoholic  insanity  . .  123 
(diagnosis)     . .          . .  159 

—  confusional  insanity    (diag- 

nosis)       . .          . .          . .  158 

—  epileptic      insanity      (diag- 

nosis)       . .          . .       161,  165 

—  hysterical  insanity  . .          . .  82 


PAGE 

Chronic  mania  . .  . .  . .     92 

—  morphismus  . .         . .   155 
Circular  insanity  . .  . .     51 

(etiology) 187 

(prognosis)  . .  . .   174 

Circulation,  defective  facial    . .     22 
Claustrophobia  29,  105,  158 

—  (prognosis)     . .  . .  . .   184 

Classification,  Bra's      . .  . .       5 

—  by    International    Congress 

of  Alienists     -     . .  . .       3 

—  by      London 

Physicians 

—  Clouston's 

—  Esquirol's 

—  Krafft-Ebing's 

—  Morel's 


College      of 


..5,6 

v,2 

v,  4,  9 

..       2 


—  Skae's  . .  . .  . .       4 

—  Spitzka's       . .  . .  V,  6 

—  of  mental  diseases  . .  . .  2 
Clergyman's      certificate      for 

paying  patients  (Ireland)  312 
Climacteric  insanity     . .  . .     53 

(diagnosis)  . .  . .   164 

(etiology)  . .         . .   137 

(pathology)  . .         . .  193 

(prognosis)  . .  . .   174 

(treatment)         . .  . .   263 

Clouston's  classification  . .  5,  0 

—  percentages  of  frequency  of 

forms  of  insanity  . .   169 
Coarse  brain  disease     . .          . .     54 
—    m sanity    from    (etio- 
logy)          ..          ..137 

—  — ■ (prognosis)  . .   174 

(pathology)    . .  . .   193 

— (treatment)   . .  . .   263 

Cocainism,  chronic  treatment  268 
Codeia  in  motor  excitement  . .  246 
Colour  of  cerebral  substance  . .  190 
Coma,  or  somnolence   . .  . .     15 

Commissioner's  classification  2 

Commissioners      in      Lunacj", 

report  of,  1889    . .  . .   134 

Committal  warrant  (Ireland)  306 
Commitment  of  patients  (New 

York  State)         . .  . .   314 

Company  low,  disposition  for . .  33 
Complexion,  pale  and  pasty  . .  15 
Corapound  hallucinations  . .  26 
Concentration    of    intellectual 

operations  round  on  e  idea    15 

—  of  thoughts  on  health,  etc.  15 
Conceptions        . .  . .  . .     29 

—  imperative     . .  . .         . .   104 


GENERAL   INDEX. 


327 


Conditions,     barometric 

seasonal  . . 
Conduct  etc.,  change  in 

—  extraordinary 
Confusion,  feeling  of     . . 

—  of  ideas 
Confusional  insanity    . . 

chronic  (prognosis) 

(etiology).. 

(pathology) 

primary  or  acute  (diag- 
nosis) . .  . .   162 

(prognosis)     . .  . .   174 

Congenital  abulia  . .  . .   167 

— •  imbecility      . .  . .  . .     83 

—  mental  and  moral  weakness  133 
Congress,  Internationa],  1867..  135 
Conium  in  motor  excitement . .  245 
Coiuiecticut,  certification  of  the 

insane  in  the  State  of  . .  316 
Connections  of  the  cerebellum 

with  the  cerebrum  . .   227 

Consciousness,  abolished         . .     15 

—  confused        . .  . .  . .     15 

—  impaired        . .  . .  . .     15 

— ^  temporary  losses  of . .  ..     16 

— ■  theories  concerning  . .   227 

Consecutive  insanity     . .  . .     58 

(diagnosis)  . .       155,  163 

■  (etiology) 138 

(pathology)         . .  . .   194 

•  (prognosis)  . .  . .   175 

Consistence  of  cerebral  substance  192 
Constipation       . .  . .         . .     16 

Continuity,  want  of,  in  thought 

and  action  . .  . .     16 

Contractures,  ruuscular  . .     35 

Conversation    by    patient    not 

sustained. .         159,  162,  163 

—  sustained  by  patient  . .  155 
Convulsions  . .  . .  vii,  16 
— -  hysterical      . .          . .          . .     27 

—  infantile  succeeding  . .     31 
Cord,  vocal,  paralysed  . .  . .     47 

Countenance,  expressionless  . ,     16 
— •  expressive  of  distrust,  etc.       16 
Courage,  failure  of        . .  . .     16 

Cramps    . .  . .  . .  . .     16 

Cranium,    the     (macroscopical 

morbid  anatomy)  . .   189 

Cretinism  . .  . .  83,  85 

—  (diagnosis)     . .  . .  . .   167 

—  (etiology) 141 

—  (prognosis)     . .  . .  . .   178 

Crimes    in     connection     with 

insanity   . .  . .  . .   320 


PAGE 

PAGE 

and 

Criminal  lunatics 

..  294 

..     14 

Criminals,  the  brain  in 

..   237 

..     15 
..     15 
..     15 

Cruelty    . . 
Cursatory  impulses 
Cutaneous  anaesthesia  . . 

..     16 
..     16 
16,78 

..     15 
56,  57 
..   175 

—  sensibility,      disorders 

(morbid  anatomy) 
Cyanosis  from  bronchitis 

of 

..   202 

..     59 

..   138 
..   194 
iag- 

etc.,       insanity 

(etiology)     . . 
(prognosis)     . . 

of 

..   138 

..   175 

Darwin,  lop.  149,   240;    De- 
lasiauve,  198';  Down,  83 

Dangerous  lunatics 

(Ireland) 

committal  warrant  (Ire- 
land) 

Death  of  patient 

—  order  of  frequency  of  forms 

of  insanity  at     . .  . .   170 

Declaration  for    admission  of 

patients  (Ireland)         . .   304 

Defects  of  cutaneous  sensibility  202 


294 
303 


805 

289 


Definitions  of  insanity . 

—  of  medical  attendant 
Dejection 

Delire  des  actes . . 
Delirium  . . 

—  acute  . . 

—  —  (diagnosis) 

(etiology).. 

(pathology) 

—  —  (prognosis) 

—  —  (treatment) 

—  hallucinatory 

—  of  fevers  (diagnosis 

—  of  young  children 

(diagnosis) 

(etiology) 

— •  —  —   (prognosis) 
— ■  with  remissions 

—  with  unconsciousness 

—  tremens 

—  —  (treatment) 
Delusion  . . 
Delusions,  etc. 
— •  genuine 

—  of  ambition 

—  of  persecution 

—  of  pride 

—  of  suspicion 

—  (pathology) 
— ■  spurious 

—  systematised 

—  unsystematised 


1 

..  287 
..  16 
..  168 
..  16 
..  60 
..  165 
..  138 
..  194 
..  175 
..  263 
..  56 
..  147 
..  131 

164,  165 
..  146 
..  188 
..  17 
..  133 
..  120 
..  268 
..  132 
..  164 
..  17 
..  166 
..  156 
..  166 
..  155 
..  215 
..  18 
155 

156,  158 


GENERAL  INDEX. 


PAGE 

Delusional  insanity 

61 

(diagnosis) 

154, 

166 

(etiology) 

138 

(pathology) 

195 

—  —  (prognosis) 

175 

—  mania . . 

92 

— •  melanctiolia  . . 

97 

Demeanour,  change  of 

156 

Dementia,  acute 

117 

(etiology) 

144 

(prognosis) 

186 

—  agitated  terminal  (diagnosis) 

161 

—  alcoholic 

126 

—  epileptic  (diagnosis) 

161 

—  organic           . .              vii 

,  54, 

160 

—    paralytic 

54 

—  paretic 

71 

-  •  j)artial 

10*6, 

159 

—  puerperal 

113 

—  senile 

117, 

160 

advanced . . 

166 

—  simple  primary 

99 

—  terminal 

65 

~  —  (diagnosis) 

167 

(etiology) 

138 

(pathology) 

195 

(prognosis) 

176 

Depression 

18 

—  and  exaltation,  alternating 

12,  21 

—  with  change  of  habits 

156 

Deprivation,  idiocy  by . . 

85 

—  of  senses 

66 

insanity  from  (etiolo 

gy) 

138 

Desire,  sexual,  loss  of  . . 

216 

Despondency,  religious 

19 

Destructiveness. . 

19, 

245 

Deterioration,  mental  . . 

99 

—  moral 

34 

—  primary  mental 

159 

(etiology) 

139 

(prognosis)     . . 

176 

Devils,  animals,  etc.,  seen  by 

patient     . . 

164 

Diabetic  insanity 

66 

(diagnosis) 

163 

(etiology) 

139 

(prognosis) 

176 

Diagnosis,   differential,   of 

the 

forms  of  insanity 

154 

—  of  insanity     . . 

146 

—  references  to  paragraph 

s  on 

168 

Diarrhoea 

19 

Diet  in  home  treatment 

251 

Differential  diagnosis    of 

the 

forms  of  insanity 

154 

PAGE 

Diminutives,  tendency  to  use        19 
Dipsomania        . .  . .        80,  156 

Dirty  in  habits  . .         . .         . .     19 

Discharge,  form  of  notice  of  . .   283 
Discontentedness  . .  . .     19 

Disorders,  abdominal  . .         . .     49 

—  of  cutaneous  sensibility  (mor- 

bid anatomy)  . .  . .  202 
Disposition       and       conduct, 

change  in  . .  15, 19,  156 

—  to  cormect  all  things  with  self  15 

—  to  squander  . .         . .         . .     43 

—  to  wander      . .  . .  . .     47 

Distaste  for  work  . .  . .     48 

Distortion      of      objects      and 

persons    . .  . .  . .     19 

District        lunatic        asylums 

(Ireland)      ..  ..303 

rules  for  (Ireland)   . .   309 

Disturbance,  emotional  . .     20 

—  —  of  bodily  functions  . .  . .     14 

—  auditory  (morbid  anatomy)    204 

—  gustatory       . .  . .  . .  206 

—  intestinal      . .  . .  . .     32 

—  olfactory  (morbid  anatomy)  206 

—  trophic  . .         . .  . .     46 

—  visual  (morbid  anatomy)  . .  205 
Doubting  insanity         . .  . .     70 

(diagnosis)  . .         . .   158 

Dread,  unfounded         . .  . .     19 

Dreaming,  theory  of     . .         . .  235 

Dreaminess        . .  . .         . .     19 

Dress  and  undress,  inability  to      19 

—  suggestive  of  exalted  ideas       19 
Dressing  fantastically,  etc.     . .     19 
Drink,  intense  craving  for      . .     19 
Drinking  and  eating,  excess  in      21 
Drowsiness         . .         . .         . .     20 

Drugs   and   alcohol,   increased 

reaction  to  . .  . .     39 

Dulness  and  indifference  . .  20 
Dura  mater,  the  (macroscopical 

morbid  anatomy)  . .   189 

Durhsematomata  . .  . .   189 

Duties  of  medical  attendant  . .   287 

—  of  person  haAong  charge  of 

single  patient  . .  . .  280 
Dynamograph,  IMorselh's  . .  153 
Dynamometric  indications  . .  20 
Dysmenorrhoea   and    irregular 

menstruation  . .  20,  251 
Dyspepsia  . .  . .         . .     20 

ESQUIROL,  ]3p.  v.,  2,  83 

Ears,  lesions  of  . .         . ,         . .   218 

Eating  and  drinking,  excess  in      21 


GENERAL  INDEX. 


329 


Eccentricity,     insanity     from 

(diagnosis) 
Echolalia 
Eclampsic  idiocy 
Egotism,  increased 
Electric  currents,  sensations  of 

in  head    . . 

—  sensibility  abolished,  etc.    . . 
Electricity  in  home  treatment 

—  in  hysterical  insanity 
Emaciation 

Embarrassment,  gastric 
Emergency,        certificate       of 

(Scotland) 

Emissions,    nocturnal     (treat- 
ment of)   . . 

Emotions,  blunted 

Emotional  disturbance 

—  exaltation 
Energy,  diminished 
Enf eeblement,  mental . . 
England  and  Wales,  causes  of 

insanity  in 
certification    of     insane 

patients  in 
laws  as  to  keeping  single 

patients 
Enjoyment  of  life,  lost,  etc.    . . 
Ephemeral  mania 
Epilepsy  and  epileptic  insanity 
(treatment) 

—  general,  pathology  of       196, 
Epileptic  dementia  (diagnosis) 

—  insanity  (etiology)  . . 

—  fits      . .  . .  '       . . 

—  idiocy . . 

—  insanity 

—  —  (prognosis) 

—  seizures 

Epileptiform  attacks  . . 
Epileptisches  irresein  . . 
Erotic  ideas  or  tendency 

—  tendency 
Erotomania 

—  (diagnosis)     . . 
Esquirol's  classification 
Etiology  . . 

Evidence  the,  of  the  insane 
Evil  presentiments  of  . . 
Exacerbations     at     menstrual 

periods 

—  nocturnal 
Exaggeration,  ideas  of. . 

—  of  trifles 

—  proneness  to . . 
Exaltation 


Exaltation      and      depression 

146 

alternating          . .          12, 21 

20 

—  emotional 

132 

84 

—  partial 

106 

20 

(etiology) 

143 

—  —  (prognosis) 

184 

27 

—  v?itli  change  of  habits 

157 

20 

Examination     of     patient    in 

252 

asylum     . . 

279 

265 

—  of  sexual  organs 

153 

20 

Examination  of  single  patient 

279 

23 

Examining  a  patient,  method  of  150 

Excess,  sexual    . . 

21 

300 

—  in  eating  and  drinking 

21 

—  alcoholic  tendency  to 

12 

252 

Excited  melancholia     . . 

97 

21 

Excitement,  motor  and  menta' 

22 

20 

—  sexual 

42 

132 

Exciting  causes  of  insanity     . . 

135 

21 

Excretions,  deficient     . . 

22 

83 

Exercise  in  home  treatment  25! 
Exertion,  mental   and   bodily 

L,256 

134 

incapacity  for 

22 

Exhaustion,  nervous     . . 

22 

269 

Exophthalmic  goitre,   insanity 

with  (etiology)       6£ 

,139 

279 

—  ■ of  (treatment) 

264 

21 

with  (diagnosis) 

163 

92 

Expenditure,    extravagance  as 

to,  etc. 

22 

263 

Expression,  facial 

22 

239 

—  vacant 

47 

161 

Extravagance  as  to  expenditure 

) 

139 

etc. 

22 

27 

Extremities,  cold  and  bluish  . 

22 

84 

—  rigidity  of      . . 

40 

67 

—  sores  on 

43 

177 

Eyes,  averted     . . 

22 

21 

—  neuroses  affecting  . . 

35 

21 

—  downcast 

22 

67 

—  fixed    . . 

22 

21 

—  glistening 

22 

216 

—  hollow 

22 

64 

—  injected 

22 

156 

2 

134 

—  shutting 

42 

Faleet,  x>.  51 ;  Ferrier,  204, 

319 

205,  215,  229 

38 

Face,  flushed 

22 

—  haggard 

22 

21 

—  sudden  redness  of    . . 

22 

35 

Facial  circulation  defective    . 

22 

21 

—  expression     . . 

22 

21 

—  —  absence  of 

166 

21 

anxious  or  terrified 

167 

21 

intelligent  or  ecstatic    . 

167 

330 


GENERAL   INDEX. 


29, 


51, 


PAGE 

Facial  muscles,  movements  of      23 

Faculties,  intellectual,  absent 

—  reproductive,  absent 
Faradism,  reactions  to. . 
Fatigued  easily  . . 
Fatuity    . . 
Fears,  vagTie 
Features,  contracted    . . 
Feeble  grip 
Feeding,  forcible 
Feigned  insanity  (diagnosis) . . 
Female    patient,    penaltj^    for 

carnal  knowledge 
Females,  frequency  of  insanity 

occurring  in 
Fevers,  delirium  of  (diagnosis) 
Feveiishness 
Fickleness 
Fingers,  picking 
Fixed  ideas 
Flesh,  gaining    . . 
Ely  or  hide,  tendency  to 
Folds,  naso-labial,  flattened,  etc. 
Folic  a  Deux 
(etiology) 

—  —  double  forme 

—  alternaute 
— -  crrculaire 

—  du  Doute 

(etiology) 

(prognosis) 

(treatment) 

—  6pileptique    . . 

—  hysterique 

—  raisonnante  . . 

•  (etiology).. 

(prognosis) 

—  systematise   . . 
Food,  refusal  of 
Force,  want  of,  in  thought  and 

action 
Forcible  feeding 
Forensic  psychiatry 
Forgetfulness 
Form  for  admission  of  paying 

patients  (Ireland) 

—  for  criminal  lunatics 
— ■  for  receiving  pauper  lunatic  292 

—  of  certificate  of  death         . .   290 

—  of  medicalcertificate(Ireland)  302 

—  of  medical  statement       288,  290 

—  of  medical  visitation  book . .   282 
— ■  of  notice  of  admission         . .   260 

—  of  notice  of  discharge         . .   283 

—  of  urgency  order    (England 

and  Wales)  . .  . .    270 


32 
40 

152 
23 
23 
47 
23 
24 
23 

146 

287 

169 
147 
23 
23 
38 
132 
23 
23 
35 
70 
139 
51 
158 
..  51 
..  70 
..  139 
..  177 
..  266 
..  67 
..  81 
100,  113 
..  139 
..  177 
..  61 
23,  39, 247 

23 

254 

269 

23 

308 
296 


PAGE 

Forms  for  reception  of  patients 

(Scotland)  ..  ..297 

—  of  insanity    . .  . .  . .   137 

Formication       . .  . .  . .     23 

—  sensation  of  . .  . .  . .     34 

Frenosi  sensoria  acuta  . .     56 

Frenzy,  transitory         . .  . .     92 

Frequency  of  principal  forms  of 

insanity  . .  . .  . .   169 

Friends,  antipathy  to  . .  . .     39 

Fulness  in  head  . .  27,  38 

FunctionSjbodily, disturbance  of    14 

Galezowske,  j).  78 ;  Gamgee, 
221 ;  Gowers,  194,  202,  204, 
221,  225,  229  ;  Grasset,  69 ; 
Griesinger,  1,  25,  28,  58,  59, 
72,  75,  76,  82,  90,  93,  94,  95, 
97,  99,  178,  189,  190,  191, 
194,  195,  197,  199,  248; 
Guggenbiihl,  86  ;  Guy,  321 

Gaining  flesh 23 

Gait,  unsteady,  etc.       . .  . .     23 

Galvanism  in  insanity,  exoph- 
thalmic goitre    . .  . .   264 

—  reactions  to  . .  . .  . .   152 

Ganglia,  central,  cells  of  the       221 
Gastric  embarrassment  . .     23 

• —  hypochondriasis       . .  . .     95 

Gastro-enteric  insanity  . .     96 

•  (diagnosis)  . .         . .   157 

Gemiithswahnsinn        . .  . .    100 

General  epilepsy,pathoiogy  of  vi,  239 

—  mental  weakness     . .  . .   213 

—  paralysis  of  the  insane      . .     71 

(etiology)       . .  . .   139 

(pathology)    . .  . .   196 

—  prodromal  stage      . .  158 

— • (prognosis)    . .  . .   177 

(treatment)    .  .  . .   265 

—  prognosis  . .  .  ■  .  •  171 
Genetous  idiocy  . .  . .  84 
Genuine  delusions  . .  . .  17 
Gestational  insanity     . .          . .  80 

—  —  (diagnosis)           . .          . .  163 

(etiology) 140 

(prognosis)           .  .          •  ■  178 

Gesture,  constantly  making  the 

same        . .         . .          . .  16 

Giddiness            . .          . .          . .  23 

Giving  away  property  . .          . .  23 

Glance,  vivacious          . .          . .  24 

Gland,  thyroid,  lesions  of       ..  217 

Gloominess         . .          . .          . .  24 

Goitre,  exophthalmic,  insanity 

with          69 


GENERAL   INDEX. 


331 


PAGE 

Gouty  insanity  . . 

(diagnosis) 

•  (etiology) 

(prognosis) 

Grave  delirium  . . 

..   110 
155, 157 
..   143 
..  184 
..     60 

Grayness,  premature    . 
Grinding  teeth  . . 

..     38 

..     24 

Grip,  feeble 
Groaning . . 

..     24 
..     24 

Grouping  of  forms  of  mental 

aberration  . .         . .   131 

Gunjah,  insanity  from  (diag- 
nosis )       . .  . .         . .   165 

Gustatory  disturbances  (morbid 

anatomy) . .         . .  . .   206 

— ■  hallucinations  . .  24,  25 

Gyratory  impulses        . .  . .     24 

HackTuke,pp.  253, 263, 317  ; 

Hoffbaner,   85 ;    Huchard, 

67,  81 
Habits,  change  of  . .        24,  156 

—  dirty  in  . .  . .  . .     19 

—  wet  in  . .  . .  . .     48 

Hachish,  insanity  from  (diag- 
nosis)       . .  . .  . .   165 

Heematoma  auris          . .  . .     24 

Hgemic  causes  of  insomnia  . .   226 

Hsemorrhages,  mucous  24,  80 

Hair,  lesions  of  . .          . .  . .   218 

—  pulling  out    . .          . .  . .     38 

Hallucinations  . .          . .  132,  164 

—  auditory         . .          . .  . .     25 

—  compound     . .          . .  . .     26 

—  gustatory      . .         . .  24,  25 

—  in  chronic  alcoholic  insanity  123 

—  of  smell         . .         . .  26,  42 

—  production  of           . .  . .   239 

—  sexual            . .          . .  . .     26 

—  simple            . .          . .  . .     24 

—  tactual,  etc.  . .          . .  . .     26 

—  visceral          . .          . .  . .     26 

Hallucinatory  delirium  . .     56 

—  psychoneurosis  . .  . .  56 
Hands,  wringing  of  . .  . .  48 
Happiness,  feeling  of  . .  . .  26 
Head,  flashes  of  heat  to  . .     27 

—  large  . ,         . .         . .  . .     27 

—  measurement  of      . .  . .   152 

—  pains  in         . .          . .  . .     27 

— ■  sensation  of  electric  cur- 
rents in    . .          . .  . .     27 

—  fulness  in      . .          . .  . .     27 

—  pressure  in  . .          . .  . .     27 

—  temperature  of        . .  . .     45 

—  very  small     . .          . .  . .     27 


PAGE 

Headache  . .  . .  26,  73 

Hearing  impaired          . .          . .  27 

—  voices . .          . .          . .          . .  27 

Heart,  lesions  of           . .          . .  216 

—  palpitation  of  . .  . .  27 
Heat,  flashes  of,  to  head         . .  27 

—  sense  abolished,  etc.           . .  27 
Hebephrenia       . .          . .          . .  Ill 

Height  and  weight  of  patient  152 

Hemianeesthesia            . .          . .  27 

Hemiplegia         . .          . .          . .  27 

Henbane  in  insomnia  . .          . .  244 

Home  treatment           . .          . .  249 

—  —  minor  details  in  forcible 

feeding  during        . .  255 

Homicide  or  suicide     . .          . .  248 

Homicidal  impulse       . .          . .  27 

—  mania            . .          . .          . .  156 

Hopelessness      . .          . .          . .  27 

Hospitals,  lunatic         . .          . .  260 

Husband  and  children  injuring     31 

—  having  charge  of  wife         . .  286 

—  repugnance  to  . .  . .  40 
Hydrocephalic  idiocy  . .  . .  84 
Hygiene  and  therapeutics  . .  242 
Hyoscine  hydrobromate  . .  244 
Hyoscyamine  in  insomnia      . .  244 

—  motor  excitement    . .          . .  246 

Hyperacousia     . .          . .          . ,  27 

Hypereesthesia,  cutaneous      . .  27 

Hyperkinesis      . .          . .          . .  86 

Hypnotism,  hypothesis  as  to  vii,285 

—  in  home  breatment  . .          . .  253 

—  in  insomnia  . .          . .          . .  245 

Hypnotics           . .          . .          . .  243 

Hypochondriacal  melancholia  94 
Hypochondriasis           . .     27,  81,  95 

—  sexual            . .          . .          . .  96 

Hyperbulia         . .          . .          . .  27 

Hypocrisy,  self-accusations  of  41 

Hypomania         . .          . .          . .  90 

Hysteria 27 

Hysterical  convulsions             . .  27 

—  insanity         . .          . .          . .  81 

(diagnosis)           . .          . .  166 

(etiology) . .         . .          . .  140 

(prognosis)           . .          . .  178 

■ (treatment)         . .          . .  265 

chronic  (diagnosis)        . .  162 

Hystero-epileptic  fits   . .          . .  27 

Ireland,  ^p.  70,  83,  84,  85, 

149,  239 

Ideas  about  sin  . .          . .          . .  42 

—  ambitious      . .          . .          . .  12 

—  and  words,  automatic        . .  14 


332 


GENERAL  INDEX. 


PAGE 

Ideas,    concentration  of  intel- 
lectual operations  round 

one  set  of           . .          . .  15 

—  confusion  of  . .          . .          . .  15 

—  erotic,  or  tendency  . .          . .  21 

—  exalted,  dress  suggestive  of  19 

—  fixed 29,  132 

—  incorrect  of  place    . .          . .  38 

—  mobile  and  futile     . .          . .  27 

—  mobility  of    . .          . .          . .  34 

—  multiple,  absurd,  etc.        . .  27 

—  of  exaggeration        . .          . .  21 

—  of  persecution          . .          . .'  37 

—  of  poisoning  . .          . .          . .  38 

—  of  satisfaction  . .  . .  41 
•  -  of  time,  incorrect  . .  . .  46 
— •  of  unworthiness       . .          . .  47 

—  of  wealth        . .          . .          . .  48 

—  painful           . .          . .          . .  36 

—  paucity  of      . .          . .         . .  28 

Ideation,  slowness  of    . .          . .  42 

Ideenjagd           . .          . .          . .  vii 

Identity,  naistakes  of    . .          . .  28 

Idiocy 83,  166 

—  (pathology) 197 

—  (prognosis)     . .         . .          . .  178 

—  (treatment)   . .          . .         . .  265 

—  pronounced  cases  of           . .  167 

—  and  imbecility  (diagnosis)  161 
(etiology)..         ..          ..  141 

—  by  deprivation          . .         . .  85 

—  the  brain  in 237 

Idiot,   committal   warrant   for 

dangerous  (Ireland)  . .  306 

Ill-being,  sense  of          . .  . .  28 

Illinois,  certification  of  the  in- 
sane in  the  State  of  . .  316 
Illness  of  patient          . .  . .  287 

Ill-treatment  of  patient  . .  286 

Illusions  . .          . .         . .  . .  28 

Imagination  weakened  . .  29 

Imbeciles            . .         . .  . .  157 

Imbecility           . .         . .  . .  85 

—  congenital     . .          . .  . .  83 

—  (prognosis)     . .          . .  . .  178 

—  (treatment)   . .         . .  . .  265 

—  and  idiocy  (diagnosis)  . .  161 
(etiology) . .          . .  . .  141 

—  with  epilepsy  . .  . .  166 
Immediate   relief  of   urgent 

symptoms  . .  . .   243 

Immoral,  grossly  and  openly  . .     29 
Impaired  sight  . .  . .  . .     42 

Impatience         . .  . .  . .     29 

Imperative  conceptions  29,  104 

Impiety,  self-accusations  of   . .     41 


PAGE 

Improvidence  of  actions  . .  30 

Impulse,  homicidal  . .  . .  27 

—  morbid           . .            30,  132,  156 

—  cursatory       . .  . .  . .  16 

—  gyratory        . .  . .  . .  24 

Impulsive  insanity  . .  . .  86 

(etiology)..  ..  ..  141 

-    —  (diagnosis)  . .         . .   156 

(prognosis)  . .         . .   178 

Inability    of    patient    to    feed 

himself 247 

—  to  write  . .  . .         . .     48 

Incoherence       . .         . .         . .     30 

Inconsistencies  in  speech  and 

acts          . .          . .          . .  31 

Indecision           . .         . .          . .  31 

Index  to  paragraphs  on  diag- 
nosis        . .         . .         . .  168 

Indications,  dynamometric     . .  20 

Indifference        . .          . .          . .  81 

—  and  dulness  . .          . .         . .  20 

Inertia     . .          . .          . .          . .  31 

Infantile  convulsions,  succeed- 
ing           . .         . .         . .  31 

Infant,  perceptions  of  an  . .  221 
Inflammations,     delirium      of 

(diagnosis)  . .  . .   147 

Inflammatory  idiocy  . .  . .  85 
Influenza  . .  vi,  243,  252 

Inhibitory  insanity  . .  . .  86 
Inhibition,  loss  of  power  of  . .  31 
Injuring  husband  and  children    31 

—  self 31 

Inquietude  . .  . .  . .     31 

Inquisition,  persons  found  lun- 
atic by 290 

Insane,  adraission  into   State 

Hospital,  New  York     . .   316 

—  certification  of,  in  the  State 

of  Connecticut  . .         . .   316 

Illinois  . .         . .   316 

Massachusetts  . .   316 

._  New  York     . .  . .   314 

Peimsylvania  . .   316 

—  commitment  of  (New  York 

State) 314 

—  general  paralysis  of  the     . .  71 

(etiology)        . .          . .  139 

(prognosis)     . .          . .  177 

—  —  —  (treatment)   . .          . .  265 

—  in  Ireland,  certification  of  301 

—  Scotland,  certification  of  . .   296 

—  patients,  certification  of  in 

England  and  Wales      . .   269 

—  responsibility  of  the  . .  320 

—  testamentary  capacity  of  the  317 


GENERAL   INDEX. 


333 


PAGE 

Insane,  the  evidence  of  the    . .   319 
Insanities,       primary,       cases 

of 241 

Insanity,  acute  alcoholic  (prog- 
nosis)       . .  . .  . .   187 

—  adolescent     . .  . .  . .     49 

(diagnosis)  . .       157,  163 

(etiology) 137 

(prognosis)  . .  . .   173 

(treatment)         . .  . .   263 

—  advanced     chronic     confu- 

sional  (diagnosis)  . .  162 

—  alcoholic        . .          . .  . .  120 

(pathology)         . .  . .  202 

—  amenorrhceal           . .  . .  131 
— •  —  (diagnosis)           . .  . .  163 

(etiology)             . .  . .  145 

— •  — ■  (prognosis)           . .  . .  188 

—  anaemic          . .          . .  . .  50 

— ■  —  (diagnosis)          . .  . .  157 

(etiology) 137 

(prognosis)          . .  . .  173 

—  cataleptic      . .          . .          . .  50 

—  —  (diagnosis)          . .          . .  166 

(etiology) 137 

(iDrognosis)           . .          . .  178 

—  causes  of       . .          . .         . .  137 

—  choreic           . .         . .          . .  50 

(etiology) 137 

(pathology)         . .          . .  193 

(prognosis)           . .          ■  ■  173 

(treatment)         . .          . ,  262 

—  chronic  alcoholic     . .         . .  123 

—  —  —  (diagnosis)    . .          . .  159 
confusional  (diagnosis)  158 

—  —  epileptic  (diagnosis)      . .  161 
— •  —  hysterical  (diagnosis)   . .  162 

—  circular         . .         . .         . .  51 

—  —  (etiology) 137 

(prognosis)          . .         . .  174 

maniacal    phase    (diag- 
nosis)         163 

—  climacteric   . .         . .          . .  53 

(diagnosis)           . .          . .  164 

(etiology) 137 

(pathology)         . .          . .  193 

—  —  (prognosis)          . .         . .  174 
(treatment)         . .          . .  263 

—  confusional  , .          . .          . .  56 

(etiology)             . .         . .  138 

(pathology)         ..  ..394 

■  chronic  (prognosis)       . .  175 

■  primary  (prognosis)      . .  174 

—  consecutive  . .          . .         . .  58 

(diagnosis)          . .       155,  163 

(etiology)  ..         ..138 


PAGE 

Insanity,     consecutive     (path- 
ology)         194 

(prognosis)          . .          . .  175 

—  cyanosis    from    bronchitis, 

etc.  (prognosis)  . .          . .  175 

—  definitions  of            . .          . .  1 

—  delusional     . .          . .          . .  61 

(diagnosis)          . .       154,  166 

(etiology) 138 

(pathology)          . .          . .  195 

(prognosis)           . .          . .  175 

—  diabetic          . .          . .          . .  66 

(diagnosis)           . .          . .  163 

(etiology) 139 

(prognosis)           . .          . .  176 

—  diagnosis  of  . .          . .          . .  146 

—  differential  diagnosis  of  the 

forms  of  . .          . .          . .  154 

—  doubting  (diagnosis)           . .  168 

—  epileptic        . .          . .          . .  67 

—  -    (etiology) 139 

(prognosis)          . .          . .  177 

(treatment)         . .          . .  263 

—  feigned  (diagnosis)  . .          . .  146 

—  forms  of         . .          . .          . .  137 

—  in  which   crimes  are  com- 

mitted        320 

—  met  with  in  asylums          . .  170 

—  frequency  of    forms   of   at 

death        170 

—  principal  forms  of  . .          . .  169 

—  from    abdominal    disorders 

(etiology) 137 

—  absinthe         . .          . .          . .  126 

—  asthma  (diagnosis)  . .          . .  165 

—  bronchitis  (diagnosis)         . .  165 

—  cannabis  indica        . .          . .  127 
(diagnosis)     . .          . .  165 

—  cardiac  disease  (diagnosis)  165 

—  chloral           127 

—  coarse  brain  disease   (diag- 

nosis)       . .          . .         . .  160 

(etiology) . .          . .  137 

■ (prognosis)          . .  174 

—  cyanosis  (diagnosis)            . .  165 

—  deprivation  of  senses         GG,  138 

—  eccentricity  (diagnosis)      . .  146 

—  lead 127 

—  mercury        . .          . .          . .  129 

—  morphia  (diagnosis)            . .  164 

—  opiunr            . .          . .          . .  126 

■  (diagnosis)           . .          . .  164 

•  (prognosis)          . .          . .  188 

—  gastro-enteric           . .          . .  96 

—  gestational    . .          . .          . .  80 

(diagnosis)          . .          . .  163 


334 


GENERAL   INDEX. 


PAGE     1 

PAGE 

Insanity,  gestational  (etiology) 

140    1 

Insanity  of  paralysis  ag 

itans  . .  105 

(prognosis) 

178    ' 

—  ■ (etiology) 

..   143 

—  gouty  (diagnosis)      . . 

155 

—  (prognosis)     . 

..   184 

-  —  (etiology) 

143 

—  of  phosphaturia 

..   105 

—    --  (prognosis) 

184 

(etiology) 

..  143 

—  hypochondriacal 

94 

—  (prognosis) 

..   183 

—  hysterical 

81 

—  of  prisoners  . . 

..   295 

(diagnosis) 

166 

—  of  puberty     . . 

..   Ill 

—  —  (etiology). . 

140 

—  old  maid's 

..   104 

--   — •  (prognosis) 

178 

—  —  (etiology) . . 

. .  142 

(treatment) 

265 

—  —  (prognosis) 

..  183 

—  impulsive 

86 

ovarian 

..   104 

—  —  (diagnosis) 

156   i 

(diagnosis) 

..   156 

(etiology) . . 

141   : 

—  —  (etiology) 

..   142 

(prognosis) 

178   , 

(prognosis) 

..   183 

katatouic 

88   ' 

Insanity,  paralytic 

..     54 

— '  —  (etiology). . 

141 

—  partial  (diagnosis)  . 

..   167 

—    lactational    . . 

89 

—  pellagrous 

..   107 

(diagnosis) 

164      ; 

—  --  (diagnosis) 

. .   163 

(etiology) . . 

141    1 

—  —  (etiology) . . 

..   143 

—  —  (prognosis) 

179   ! 

(prognosis) 

..   184 

—  legal  tests  of . . 

320   i 

—      -  (treatment) 

..   267 

—  masturbational  (diagnosis) 

—  periodical 

..   107 

157,  161 

163    j 

—  —  (diagnosis) 

..   158 

(etiology) 

141 

(etiology) 

..   143 

(prognosis) 

181    1 

(pathology) 

..   200 

(treatment) 

263 

—  —  (prognosis) 

..   184 

—  menstrual 

107   ■ 

—  phthisical 

..   108 

—  metastatic 

100 

(diagnosis) 

.      154,  155 

—  —  (diagnosis) 

163 

(etiology).. 

..   143 

(etiology) 

142 

—   —  (prognosis) 

..   184 

(prognosis) 

183 

—  physical  causes  of    . 

.      134,  135 

—  mild  choreic  (diagnosis)    . . 

162 

—  podagrous 

..   110 

—  moral 

100 

—    -  (etiology) . . 

..   143 

(etiology). . 

142 

(prognosis) 

..   184 

(prognosis) 

183 

—  post-connubial 

..   Ill 

causes  of  . .          . .      134 

,  135 

(diagnosis) 

..   162 

—  neurasthenic 

101 

—  —  (etiology) 

..   143 

■  (etiology) 

142 

(prognosis) 

..   184 

(prognosis) 

183 

—  post-febrile    . . 

..     58 

—  no  two  cases  alike   . . 

145 

—  predisposing  causes 

of       ..   135 

—  of  Bright's  disease   . . 

50 

—  primary  or  acute  cor 

fusional 

(etiology) 

137 

(diagnosis) 

..   162 

—  —  —  (prognosis)     . . 

173 

-  -  principal  forms  of   . 

..       2 

—  of     cardiac      disease      and 

—  pseudo  of  somnamb 

alism  . .   117 

asthma    . . 

59 

(prognosis)     . 

..   186 

—  of  cyanosis  from  bronchitis 

59 

—  pubescent 

..   Ill 

—  of  masturbation 

92 

—  —  (diagnosis) 

..   163 

—  of  myxcedema 

101 

(etiology) . . 

..   143 

(diagnosis) 

161 

' (prognosis) 

..   184 

(etiology) . . 

142 

(treatment) 

..   263 

(prognosis) 

183 

—  puerperal 

..   112 

(treatment) 

266 

(etiology) 

..   143 

—  of  oxaluria    . . 

105 

—  —  (pathology) 

..   200 

(etiology) 

143 

■  (prognosis) 

..   185 

—   —  (prognosis) 

183 

—  —  (treatment) 

..   267 

GENERAL   INDEX. 


335 


(cliag- 


Insanity,  reasoning 

—  rheumatic 

—  —    (diagnosis) 

(etiology).. 

(prognosis) 

—  saturnine 

—  —  (diagnosis) 

(pathology) 

(prognosis) 

comatose     form 

nosis)    . . 

—  senile  . . 
(etiology) . . 

—  —  (pathology) 
(prognosis) 

—  — •  (treatment) 

—  severe  choreic  (diagnosis) . . 

—  Sibbald's        gastro  -  enteric 

(etiology) 

— -  stuporous 

(etiology) 

—  supervening  suddenly 

—  symptoms  of.. 

—  syphilitic 

(diagnosis) 

(etiology) 

(pathology) 

(prognosis) 

—  —  (treatment) 

—  —  expansive  -(diagnosis)   . . 

—  toxic   . . 

(etiology) 

(patholog) ) 

—  —  (prognosis) 

—  —  (treatment) 

—  transitory  neurasthenic 

—  traumatic 

(diagnosis) 

(etiology).. 

—  —  (pathology) 
--  —  (prognosis) 

. —  treatment  of  special  forms  of 

—  uterine 
(diagnosis)  . .       163, 

—  —  (etiology) 

(prognosis) 

"-  weight  of  brain  in    . . 

—  with  Bright's  disease  (diag- 

nosis) 

—  with  exophthalmic  goitre  . . 

(diagnosis)     . . 

—  (etiology) 

—  with       paralysis 

(diagnosis) 
Insomnia 

—  (therapeutics) 


AGK 

113 
114 
161 
144 
185 
127 
161 
202 
188 

162 
116 
144 
200 
186 
263 
162 

187 
117 
144 
254 
240 
118 
159 
144 
201 
186 
267 
163 
120 
144 
202 
187 
267 
103 
129 
164 
145 
202 
188 
262 
131 
164 
145 
188 
192 

163 

69 

163 

189 

155 

81 

243 


PAGE 

Insomnia,  exciting  causes  of  . .   226 

—  in  home  treatment  . .   251 
Instability          ..          ..  ..     32 

Instruction,  incapable  of         . .     32 
Interest,  loss  of  in   surround- 
ings . .  . .  . .     32 

International  Congress  of  1867  135 

Interrogation  of  self     . .          . .  41 

Intestinal  and  stomach  lesions  217 

Intestinal  disturbances  . .  32 
Intoxication,      alcoholic      and 

other  (diagiiosis)            . .  148 

Intractability  and  wildness     . .  48 

Introspection,  shallow,  etc.    . .  32 

Irascibility          . .          . .          . .  32 

Ireland,    certification    of     the 

insane  in. .          . .          . .  301 

Irritability           . .          . .          . .  32 

Irritation  of  skin           . .          . .  42 

Jacksonian    epilepsy      (treat- 
ment)      , .          . .  . .  264 
Jaws,  champing  of        . .  . .  32 
Jealousy,  insane            . .  . .  32 
Judgment,  defective     . .  . .  32 

—  ■ —  morbid  anatomy  of  . .  213 

—  —  weighing  own     . .  . .  48 

Kahlbaum,  pp.  26,  88,  89  ; 
Kolk,  49;  Krafit  -  Ebing, 
4,  9,  26,  41,  42,  46,  56,  67, 
61,  65,  71,  90,  96,  100,  101, 
104,  129,  139,  142,  177, 
242,  244,  246,  250,  253 

Katatonia     or     katatonic    in- 
sanity 

—  cataleptic  phase  of 

—  (etiology) 

—  (pathology)    . . 

—  (prognosis 
Kidneys,  lesions  of 
Kill,  impulse  to. . 
Kleptomania 
Krafft-Ebing's  classification 

—  —  recent  classification 

Lewis  (Bevan),  pp.  39,  69, 
185,  190,  191,  195,  196, 
197,  199;  Lombard,  45; 
Luciani,  208,  221 ;  Luys, 
2.39 
Lactational  insanity  . .  . .  89 
(diagnosis)           . .          . .  164 

—  —  (etiology)  . .  . .   141 

■ (prognosis)  . .  . .   179 

Language,  obscene,  etc.  . .     32 


. .  vi,  88,  161 

.   166 

.    141 

.   199 

.   179 

.   217 

.     32 

.   156 

;ation  . 

4 

tion 

.  v,  9 

336 


GENERAL   INDEX. 


PAGE 

Language,  incoherent  . .         . .  165 

Lassitude  . .         . .         . .     32 

Laughter 32 

—  motiveless     . .  . .  . .     34 

Laws     as     to    keeping    single 

patients,    England    and 

Wales 279 

—  of  1889  (New  York  State)  . .  315 
Laziness  . .          . .         . .          . .  32 

Lead,  insanity  from     . .          . .  127 

Legal  regulations           . .          . .  269 

—  tests  of  insanity  . .  . .  320 
Lesions  of  non-nervous  organs  216 

Lethargy             33 

Life,  enjoyment  of  lost            . .  21 

Listlessness         . .          . .          . .  33 

Lip,  swelling  of  upper              . .  47 

Liver,  lesions  of . .         . .          . .  217 

Localisation,  cerebral  . .         vi,  202 

Localised  paralj'sis       . .          . .  33 

Lochia  altered,  etc.       . .          . .  33 

Locomotion,  disturbances  of  . .  33 
London  college  of   physicians' 

classification          . .          . .  8 

Loquacity           . .          . .          . ,  33 

Loss  of  ability  to  write             . .  33 

— -  of  self-confidence     . .          . .  41 

—  of  self-control            . .          . .  41 

—  of  sexual  desire  . .  . .  216 
Low  company,  disposition  for  33 
Lunacy  Act,  1890,  prosecution 

under 278 

—  report  of  the  commissioners 

in,  1889 134 

Lunatic  Asylum,  admission  to 

(Ireland) 303 

rules  for  (Ireland)         . .   309 

—  hospitals        . .  . .  . .   260 

—  order    for    transmission    of 

(Scotland)  ..  ..300 

Lunatics,  admission  into  State 

hospitals.  New  York     . .   316 

—  by  inquisition  . .  . .   290 

—  certification  of,  in  the  State 

of  Connecticut        . .   316 

Illinois  . .         . .   316 

■  Massachusetts  . .   316 

Pennsylvania  . .   316 

—  commitment  of  (New  York 

State) 314 

—  committal       warrant      for 

dangerous  (Ireland)     . .   306 

—  criminal         . .  . .  . .   294 

—  cruelly  treated         . .  . .   294 

—  dangerous      . .         . .  . .   294 

(Ireland) 303 


PAGE 

Lunatics,  legal  tests  of  . .   320 
— ■  (not  pauper)  not  under  con- 
trol            294 

—  pauj)er            . .          . .  . .  291 

— •  responsibility  of       . .  . .   320 

—  testamentary  capacit)'  of  . .   317 

—  the  evidence  of        . .  . .   319 
— •  uncertified     . .          . .  . .  291 

—  wandering     . .          . .  . .   294 

Lungs,  lesions  of           . .  . .   216 

Lycanthropia     . .          . .  . .   156 

Lj^emania         . .          . .  . .     93 

Lypothymia        . .          . .  . .     93 


Magnan,  pp.  45,  62,  63,  69, 
121, 122,  123, 124,  125,  126, 
187, 188,  258 ;  Marce,  51, 87; 
Maudsley,  86,  88,  172,  181, 
183, 188, 196,  220,  236,  238, 
319,  320 ;  Mas  ]\Iiiller,  149 ; 
Mendel,  56,  90;  Mercier, 
320;  Merson,  53;  Mejmert, 
191,  196,  199,  201,  204, 
218,  219,  221,  222,  223,  225, 
227,  228,  231,  239,  262; 
Mickle,  72,  75,  193,  197, 
199,  200,  210  ;  Morel,  2,  5  ; 
Morselli,  56,  70,  71,  86,  88, 
107,  129,  153,  236 ;  Monti, 
40;  Miinsterberg,  153 

Magistrates'      certificate      for 

paying  patients  (Ireland)  312 
..47 
. .     33 


Making  words 

Malaise 

Males,   frequency    of    insanity 

occurring  in        . .  . .  169 

IMania      . .         . .  . .  . .     89 

—  (etiology)       . .  . .  . .   141 

—  (pathologj^) 200 

—  (prognosis)     . .  . .  . .   179 

—  acute  (diagnosis)  . .  . .  163 
— ■  chronic  advanced  (diagnosis)  162 

—  delusional  (diagnosis)         . .  165 

—  destructive  (diagnosis)       . .   156 

—  hallucinatoria  . .  . .     56 

—  in  young  children    . .  . .  238 

—  periodical  (diagnosis)  . .   163 

—  puerperal      . .  . .         . •   112 
"  —  —  (diagnosis)  . .         . .  163 

—  senile  . .  . .  •  •  116 
(diagnosis)  . .         . .  161 

—  simple  . .         •  •         . .     90 

—  transitory  (diagnosis)  . .  165 
]\Ianie  sans  delire  . .  . .  100 
Manipulations,  awkwardness  in    33 


GENERAL   INDEX. 


337 


PAGE 

Manner,  fierce    . .  . .         . .  33 

—  foolish  33 

—  jolly 38 

Manual  inability,  etc.  . .  . .  88 

Marasmus  .  . .         . .  33 

Massachusetts,  certification  of 

insane  in  the  State  of  . .  316 
Massage  in  home  treatment  . .  253 
Masturbation      . .         . .  . .     33 

—  self-reproaches  of  . .  . .  41 
Masturbational  insanity         . .     92 

(diagnosis)  157,  161,  163 

(etiology)..  ..  ..   141 

(prognosis)  . .  . .   181 

(treatment)         ..  ..263 

Masturbatory  melancholia  . .  165 
Medical  attendant,  definition  of  287 
duties  of  . .  . .  . .   287 

—  certificate  (Scotland)         . .  299 

—  —  for     dangerous    lunatic 

(Ireland)  ..         ..308 

....  —  for       paying       patients 

(Ireland)  . .  . .   310 

—  certificates  (Ireland)       302,  305 

—  —  persons  disqualified  from 

signing . .  . .      278,  280 

—  superintendents,  duties  of. .   287 

—  visitation  book,  form  of  . .  282 
Medicines  in  general  paralysis 


of  the  insane 

..   265 

Megalomania 

..     63 

Melancholia 

93,  166 

—  (etiology) 

..   141 

—  (pathology)    . . 

V,  200 

—  (prognosis)     . . 

..   181 

—  (treatment)   . . 

..   266 

—  acute  (diagnosis)     . 

..   163 

—  agitated 

..     97 

—  attonita 

..     99 

—  delusional 

97,  164 

—  in  childhood 

..   238 

—  masturbatory 

..  165 

—  organic 

56,  160 

—  puerperal 

..   113 

—  religious 

..     98 

—  senile  . . 

116,  161 

—  simple 

..     94 

—  stuporous 

99,  167 

—  suicidal 

..     98 

Melancholic  frenzy  (diagnosis)   165 

Melancholy  folic  raisonnante      114 

Memory,  defective 

..     33 

morbid  anatomy  of 

..   213 

—  loss  of 

..     33 

—  of  patient 

..   155 

Mendacity 

..     33 

PAGE 

Menuigitis,  cerebral  (diagnosis)  148 

]\Ienstrual  insanity       . .          . .  107 

—  periods,  exacerbations  at  . .  21 
Slenstruation  irregular,  etc.    . .  33 

and  dysmenorrhcea       . .  20 

Mental  aberration,  grouping  of 

forms  of  . .          . .  . .   131 

—  deterioration            . .  . .     99 

—  disease,  how  developed  . .   239 

—  enf  eeblement            . .  . .     33 

—  pain 36,  131 

—  restlessness  . .          . .  . .     40 

—  torpor . .         . .         . .  . .     46 

—  treatment      . .  . .  . .   256 

—  weakness       .  .  . .  . .     33 

—  —  general     . .  . .  . .    213 

Mercury,  insanity  from  .  .   129 

Metastasis  . .  . .  . .     34 

Metastatic  insanity       . .  . .   100 

—  —  (diagnosis)  . .  . .   163 

(etiology)  ..  ..142 

(prognosis)  . .  . .   183 

Method  of  examining  a  patient  150 

Methylal  in  insomnia   . .  . .   245 

Microcephalic  idiocy    . .  . .     84 

IMigraine  . .  . .  . .  . .     34 

ililitary  patients  (Ireland)  . .   303 
Minor  details  in  home  treat- 
ment        .  .          . .  . .   255 

Misanthropic       ...       . .  . .     34 

Mischievousness,  tendency  to        34 

Mistakes  of  identity      . .  . .     28 

Mixed  causes  of  insanity  . .    136 

Moaning  . .          . .          . .  . .     34 

ilobility  of  character    . .  . .     84 

ideas         . .         . .  . .     34 

Mockery,  tendency  to  . .  . .     34 

Monomania         . .          . .  . .     61 

(diagnosis)           . .  . .   154 

•  (pathology)          . .  . .   195 

(prognosis)           . .  . .   175 

Monomonie  affective     . .  . .   100 

Monoparaplegia  . .          . .  . .     34 

Monophobia        . .          . .  . .   105 

Monoplegia         . .          . .  . .     34 

IMonopsychosis   . .          . .  . .     61 

IMonotony  of  speech  and  action    34 

thoughts  and  movements    34 

]\Iood  quickly  changing  . .     34 

Moral  causes  of  insanity  134,  135 

— -  deterioration             . .  . .     34 

—  insanity         . .          . .  . .   100 

—  —  (etiolog;y_)              . .  . .   142 
(prognosis)           . .  . .   183 

—  perverseness. .          ..  ..34 

—  treatment      . .          . .  . .   256 

22 


338 


flENERAL   INDEX 


132, 


PAGE 

.  100 

.   189 

.   202 

156 

41 

34 

214 

2 

34 

246 

267 

..    164 

..   249 

..   268 

..   155 

..   153 

..     34 

..     34 

..   245 

245,  246 

..     34 


Moralisches  irresein 
Morbid  anatomy 

—  -  -  of  symptoms 

—  impulse 

—  self-feeling     . . 

—  sensations 

—  sensiblerie 
Morel's  classification 
Moroseness 
Morphia  in  motor  excitement 

•  paranoia  . . 

insanity  (diagnosis) 

— •  —  suicidal  tendency 
Morpliinismus  (treatment) 
Morphismus,  chronic    . . 
Morselli's  dynamograph 
Motiveless  actions 

—  laughter 
Motor  excitement,  etc. 
remedies  in 

—  restlessness    . . 

—  symptoms  (morbid  anatomy 

of) 208 

Movement,  aversion  to . .  . .     36 

—  resistance  to,  etc.    . .  . .     40 
^  voluntary       . .          . .  . .     47 

—  and  thought,  monotony  of  . .     34 

—  choreic  . .  . .  . .     15 

— ■  rhythmical    . .  . .  . .     40 

Mucous  hemorrhages   . .         24,  80 
Muscles,  lesions  of        .  .  . .   217 

—  rigidity  of      . .  . .  . .     40 

Muscular  contractures  .  .         35,  79 

—  relaxation      . .  . .  . .     35 

—  resistance  diminished        . .     35 

—  sense  abolished,  etc.  . .     35 

—  weakness,  limited    . .  . .     35 
Mutilation  of  self          .  .          . .     41 

Mutism 35 

Muttering  of  patient     . .  . .   166 

—  isolated  words  . .  . .     35 
Mysophobia         . .           29,  105,  158 

—  (prognosis)     . .  . .  . .   184 

My^xcEdema,  insanity  of  . .   101 

— ■  (diagnosis)     . .  . .   161 

(etiology)        . .  . .   142 

(prognosis)     . .  . .   183 

(treatment)    . .  . .   266 

Nasse,  -p.  58  ;  Newington,  56 

Naked,  stripping  in  public       . .  43 

Naso-labial  folds  flattened,  etc.  35 

Natural  affection,  loss  of         . .  35 

Necrophilism           . .          . .   30,  156 

Neglect  of  lunatics        . .         . .  294 

Nervous  exhaustion      . .         . .  22 


PAGE 

Nervousness       . .         . .         . .  35 

Neuralgia,  general,  etc.            . .  35 

Neurasthenia      . .          . .          . .  101 

—  (prognosis)     . .          .  .          . .  183 

—  (treatment)   . .          . .          . .  266 

—  Weir-Mitchell's  treatment  of  267 
Neurasthenic      degenerative 

psychoses            . .  .  .  104 

—  insanity  (etiology)    .  ,  .  .  142 

—  psychoneuroses        . .  . .  103 

—  psychoses       . .          . .  . .  103 

Neuritis,  optic    . .          . .  . .  36 

Neuroses  afiecting  eye  . .  35 

Never  speaking  . .          . .  . .  35 

New  York,  certification  of  the 

insane  in  the  state  of     314 

Pauper  Asylum,  statistics 

of  170 

Nocturnal     emissions      (treat- 
ment) . .  .  .   252 

Nocturnal  exacerbations  . .     35 

Noisiness  . .  . .         35,  245 

Non-medicinal  treatment       . .   256 
Nosophobia         . .  . .  . .     35 

Notice  of  desire  to  have  a  per- 
sonal interview  . .   281 

—  —  discharge  form  of  . .   283 

—  —  right  to  personal  inter- 

view ..  ....   281 

Nourishment  in  motor  excite- 
ment          246 

Nymphomonia  . .  . .         30, 156 

—  (prognosis)     . .  . .  •  •   178 
Nystagmus          . .          . .  . .     36 

Ord,  p.  142 

Objects  and  persons,  distortion  of  19 


fron:i 


Obscenity 
Obstinacy 

Occupation,  change  of 
Occupations  etc.  in  home  treat 

ment 
Oddness  and  peculiarity 

birth 
Odour  exhaled    . . 
(Edema    . . 
Old  maid's  insanity 
_   —  —  (diagnosis) 

(etiology) 

—  (prognosis) 

Olfactory  disturbances 
anatomy) 
—  hallucinations 
Onanism  . . 
Opium  in  motor  excitement 


'morbid 


26 


36 
36 
36 

256 

36 
36 

104 
155 
142 

183 

206 

,  36 

41 

246 


in  insanity  (diagnosis)     126,  164 


GENERAL   INDEX. 


339 


PAGE 

188 

249 

36 

36 


276 


300 


Opium  in  insanity  (prognosis) 

—  in  suicidal  tendency 
Optic  nerve  changes,  etc. 
Optic  neuritis 
Order  for  reception  of  private 

patients    . . 

—  •  —  transmission  of  lunatic 

(Scotland) 
Organic  dementia 

—  melancliolia  . . 
Organs,  lesions  of  non-nervous  216 
Originating  power,  want  of 
Otlisematoma 
Othseinatomata  . . 
Outbreak,  abruptness  of 
Ovarian  insanity 

—  —  (diagnosis)  . .       155 
(etiology) 

—  —  (prognosis) 
Ovaries  and  uterus,  lesions  of 
Oxaluria,  insanity  of    . . 

(etiology) 

(prognosis)     . . 


vii,  54,  160 
66 


36 

24,  36 

80 

11 

104 

156 

142 

183 

217 

105 

143 

188 


Pilgrim,  p.  316 ;  Pinel,  2, 
190 ;  Prichard,  2  ;  Prit- 
chard,  24 

Painful  ideas 

—  sensations,  heat,  etc. 
Pain,  mental 
Pains 

Pallor 

Palpitation 

Paraldehyde  in  insomnia 
Paralysis  agitans 

—  —  insanity  of 
(etiology).. 

—  —  (prognosis) 

—  alcoholic,  pseudo-general 

125,160 
~    and  paresis  . . 

—  confirmed  general   . . 

—  general  (pathology) 

—  —  prodromal  stage 
--  localised 

—  of  vocal  cord  or  cords 

—  saturnine,  psexido-general 

128. 

—  syphilitic,  pseudo-general 

119, 160 
Paralytic  dementia      . .  . .     54 

—  idiocy. 
Paranoia 

—  (diagnosis) 


..     36 
..     36 

36,  131 
27,36 
.,  37 
27,  37 
243 
155 
105 
143 
184 


37 

160 

196 

158 

33 

47 

160 


—  (pathology) 

—  (prognosis) 


84 
V,  61 
154 
195 
175 


PAGE 

Paranoia  (treatment)  . .          . .  267 

—  neurasthenic . .         . .          . .  104 

masturbatory    (treat- 
ment)      . .          . .          . .  266 

—  psiconeurotica          . .          . .  56 

—  rudimentaria  impulsiva     . .  86 
Paraplegia          . .          . .          . .  37 

Paresis  and  paralysis   . .         . .  87 

—  localised        . .          . .          . .  33 

—  vaso-motor    . .          . .          . .  47 

Paretic  dementia          . .          . .  71 

Parsimony           . .          . .          . .  87 

Partial  dementia  . .       100,  159 

—  emotional  aberration         . .  105 

— (etiology)       . .          . .  143 

— ■ (prognosis)     . .          . .  184 

—  (treatment)'  . .          . .  266 

—  exaltation     . .          . .          . .  106 

(etiology) 148 

■  (prognosis)           . .          . .  184 

-- insanity  (diagnosis)            ..  167 

Passive  suffering           . .          . .  87 

Pathological  anatomy  . .          . .  189 

Pathology  and  pathogenesis  . .  218 

Pathophobia  (prognosis)          . .  184 

Pathos 37 

Patient,  absence  of  facial  ex- 
pression in         . .          . .  166 

— •  absolutely  mute      . .          . .  166 

—  and  business            . .          . .  287 

—  change  of  residence            . .  286 

—  chancery       . .          . .          . .  290 

—  commitment  of  (New  York 

State) 814 

—  death  of         289 

—  examination  of,  in  asylum  279 

—  illness  of        287 

—  ill-treatment  of        . .          . .  286 

—  inability  of,  to  feed  himself  247 

—  incoherence  of  language  of  165 

—  loquacity  of  . .          . .          . .  165 

—  making  inarticulate  noises  167 

—  military  (Ireland)    . .          . .  308 

—  method  of  examining  a      . .  150 

—  muttering  of . .          . .          . .  166 

—  non-paying,    certificate    for 

(Ireland) 812 

—  pauper           . .          . .          . .  291 

—  penalty   for    carnal    know- 

ledge of  female  . .          . .  287 

—  private,     admission     into 

State     Hospital,     New 

York         316 

—  private  order  for  reception  of  276 
petition  for         . .          . .  274 

—  refusal  of  food  bv     . .          . .  247 


340 


GENERAL   INDEX. 


PAGE 

Patient,  refusal  to  speak         . .  166 

—  removal  of  to  another  asy- 

lum   287 

—  single,    duties     of     person 

having  charge  of  . .  280 

—  suitable  for  private  care  . .  257 

—  unable  to  speak       . .  . .  167 

—  visitation  of  . .          . .  . .  287 

Pauper  asylums . .          . .  . .  259 

—  lunatics         . .          . .  . .  291 

Pazzia  catatonica         . .  . .  88 

—  epilettica       . .          . .  . .  67 

--  isterica           . .          . .  . .  81 

Peculiarity  from  birth  . .  . .  36 

Pee%T.sliness        . .         . .  . .  37 

Pellagra  (treatment)     .  .  . .  267 

Pellagrous  insanity      . .  . .  107 

(diagnosis)           . .  . .  163 

■ (etiology) 148 

—  —  (prognosis)  . .  . .  184 
Penalty  for  carnal  knowledge 

of  female  patient  . .   287 

Pennsylvania,   certification   of 

the  insane  in  the  State  of    816 
Penuriousness    . .         . .         . .     37 

Perception  and  sensation  . .  vii 
Perceptions  of  an  infant  . .  221 
Peripheral  causes  of  insomnia  226 
^        "'     "  ■  107 

158 
143 
200 
184 
37 

21 

156 

37 

281 
281 
281 

19 
294 

278 


Periodical  insanity 
(diagnosis) 

—  -  (etiology) 

(pathology; 

(prognosis) 

Periodicity 

Periods,  menstrual,   exacerba- 
tions at    .  • 

Persecutional  delusions 
Persecution,  ideas  of    . . 
Personal  inter\iew,   certificate 
as  to        . . 

—  —  notice  of  desire  to  have 

— right  to 

Persons  and  objects,  distortion 

of 

—  deemed  lunatics 

—  disqualified    from     signing 
medical  certificate 

—  found  lunatic  by  inquisition  290 
Perspiration,  profuse  . .  . .  38 
Perverseness,  moral  . .  . .  34 
Perversion,  sexual  ..  ^,107 
Petition  for  private  patient    . .   274 

—  to  the  Sheriff  (Scotland)  . .  296 
Phosphaturia,  insanity  of       . .   105 

(etiology) 148 

(prognosis)  . .  . .   188 


Photopsia 

Phrase,  repetition  of 

Phthisical  insanity 

(diagnosis) 

-    —  (etiology) 
(prognosis) 


PAGE 

..  38 
..  39 
..   108 

]54,  155 
..   143 
..184 
Physical  causes  of  insanity  134, 135 
Pia  mater,  the  (macroscopical 

morbid  anatomy) 
Picking  fingers  . . 
Pilocarpine  in  threatening 

raania 
Piscidia  erythrina  in  insanity 

—  insomnia 

Place,  desire  for  change  of 

—  incorrect  ideas  of     . . 
Planomania 

Pneumonia,  delirium  of  (diag- 
nosis) 

Podagrous  insanity 
^  —  (diagnosis) 
(etiology) . . 

—  •—  (prognosis) 
Poisoning,  ideas  of 
Post-connubial  insanity 
Post-connubial  insanity   (diag 

nosis) 

(etiolog}') 

—  (prognosis)     . . 

Post-febrile  insanity     . . 

Pot.  bromide  in  motor  excite- 
ment 

Power,  originating,  want  of 

Predisposing     causes     of 
sanity 

Pregnancy,  insanity  of 

Premature  grayness 

Pre-occupation  vdth  ideas 
about  sin . . 

Presentiments  of  evil   .  . 

Pressure  or  fulness  in  head, 
sensation  of 

—  sensation  of,  in  head 
Pride,  delusions  of 
Primary  confusional  insanity 

—  insanities,  cases  of  . . 
Prisoners  found  insane 
Private   asylums,   admission 

into  (Ireland) 
(Licensed  houses) 

—  care  (single  patients) 

—  patient,  order  for  reception 

of 

—  —  petition  for 

—  —  admission   into   State 

Hospital,  New  York     . .  314 


GENERAL  INDEX. 


341 


PAGE 


Privy  Council  regulations  (Ire 

land) 

1876  (Ireland) 

Prognosis,  general 

—  special 

Proneness  to  exaggeration 

Propensities,  morbid    . . 

Property,  giving  av^^ay  .  . 

Prophylaxis,  when  to  commence  242 

Prosecution  under  Lunacy  Act, 

1890 
Prostration 
Pseudo-insanity    of 

bulism 

(etiology) 

Psychiatry,  forensic 
Psychical  troubles 
Psychlampsia     . . 
Psychokinesia    . . 
Psychoneurosis,  hallucinatory 


transitory  neurasthenic  162, 167 

Psychoses,  neurasthenic         . .  103 

Ptosis 38 

Puberty,  insanity  of     . .          .  .  Ill 

Pubescent  insanity       . .          . .  Ill 

(diagnosis)           . .          . .  157 

(etiology) . .          . .          . .  143 

(prognosis)           . .          . .  184 

(treatment)         . .          . .  263 

Puerperal  dementia      . .          . .  113 

—  insanity         . .          . .        89,  112 
(etiology) 143 

—  —  (pathology)          . .          . .  200 

(prognosis)          . .          . .  185 

(treatment)         . .          . .  267 

—  mania             . .         . .          . .  112 

—  —  (diagnosis)           . .          . .  163 

—  melancholia  . .          . .          . .  118 

Pulling  out  hair 38 

Pulse        38 

—  slow    . .          . .          . .          . .  42 

Punctiliousness . .          . .          . .  88 

Pupils  contracted,  etc. . .          . .  88 

—  dilated           38 

—  the,  to  examine       ..          ..  152 
Pjrromania         . .         . .        30,  156 

QUAREELSOMENESS          .  .             .  .  39 

Questions   answered,  but  con- 
versation not  sustained  163 

—  answered  irrelevantly        12, 162 

—  answering  of,  by  patient    . .  154 

—  not  answered  by  patient    . .  165 
Quietude             . .          . .         . .  39 

R0BEETS0N,|J.  106 ;  Ross,  140, 
173,  230,  234 


303 

309 

171 

173 

21 

38 

23 


278 
38 

117 

144 

269 

79 

89,  93 

86 

56 


PAGE 
.       54 

.     39 

.   153 

39 

152 

113 


RamoUissement 
Reaction  time    . . 

—  —  patient's,  ascertain 

—  to  alcohol  or  drugs  increased 

—  to  Faradism 
Reasoning  insanity 
References    to   paragraphs    on 

diagnosis  . .  . .  . .   168 

Reflexes  exaggerated    . .  . .     39 

—  investigation  of  . .  . .  152 
Refusal  of  food  . .  . .  23,  39,  247 
Regulations,  legal         .  .  . .   269 

—  of     Privy     Council,      1876 

(Ireland) 309 

Relatives  and  friends,  antipathy 

to 

Relaxation,  muscular  . . 
Religious  despondency 

—  melancholia  . .  . .        98, 

—  tinge   . . 
Remedies  in  insomnia . . 

—  in.  motor  excitement       245, 
Remedial  treatment     . . 
Remissions  with  delirium 
Remorse  . . 
Removal  of  patient  to  another 

asylum 
Repetition  of  words  to  self 
Report   of    the  Commissioners 

in  Lunacy,  1889 
Reproductive  faculties  absent 
Repugnance  to  husband 
Re-representative  cognitions  and 


39 

35 

19 

164 

39 

243 

246 

248 

17 

39 

287 
39 

134 
40 
40 

214 

286 


feelings 

Residence,  change  of,  with 
patient     . . 

Resistance,  muscular,  dimin- 
ished       . .  . .  . .     35 

—  to  movement,  etc.  . .  . .  40 
Respirations,  affected  . .  . .  40 
Responsibility  of  the  insane  . .  819 
Restlessness,  mental    . .         . .     40 

—  motor. .  . .  . .  85,  40 

Restraint,     certificate     as     to 

mechanical  means  of  . .   285 
Retention  of  urine        . .  . .     40 

Retina,  changes  in        .  .  . .     40 

Rheumatic  insanity     .  .  . .   114 

—  —  (diagnosis)  . .  . .    161 

■ (etiology) . .  . .  . .   144 

(prognosis)  . .  . .   185 

Rheumatism,  cerebral . .  ..   114 

Rhyming  speech  . .  . .     40 

Rhythmical  movements  . .     40 

Rigidity,  cataleptic      .-.  ..     40 

—  of  muscles,  etc.        . .  . .     40 


342 


GENERAL   INDEX. 


PAGE 

Sandee,  p.  61 ;  Sankey,  110  ; 
SauUe,  70  ;    Savage,  1,  8, 
25,   26,  27,  58,  59,  65,  67, 
69,   73,  82,  89,  97,  98,  99, 
112,    113,   116,    127,    140, 
144,  183,  185  ;  Scliiile,  61 ; 
Sepilli,  208;    Sibbald,   49. 
96, 120, 137, 184, 187,;  Skae, 
4,  64  ;    Sioencer  (Herbert), 
vii,  220,  223,  227;   Spitzka, 
4,  6,  11,  14,  15,  17,  18,  20, 
21,   25,  26,  27,  28,  29,  30. 
33,  34,   40,  42,  46,  47,  50, 
52,  56,  57,  58,  60,  61,  62. 
64,  65,  66,  68,   71,  82,  87, 
88,  93,    99,  100,  108,   111, 
117,  118,  124, 129,  130, 131. 
138,  141,  144, 145,  170, 175, 
176,  179,  182, 184,  194,  195, 
219,  245;    Stretch-Dowse, 
201,  243  ;  Sully,  28 
Salix  Nigra  in  erotism,   emis- 
sions, etc.  . .      252,  258 
Sallowness          . .          . .  . .     40 

Satisfaction,  ideas  of    . .  . .     41 

Saturnine  insanity        . .  . .   127 

(diagnosis)  . .  . .   161 

(pathology)         . .  . .   202 

—  —  (prognosis)  . .  . .  188 
comatose  form  (diagnosis)  162 

—  pseudo-general  paralysis  128, 160 
Satja-iasis  . .  . .  30,  41, 156 
Savage's  classification  . .  . .  8 
Scotland,    certification  of  the 

insane  in . .          . .          . .  296 

Screaming          . .          . .          . .  41 

Seasonal  and  barometric   con- 
ditions     . .          . .         . .  14 

Secondary  dementia  (prognosis)  176 

Secretions,  diminished            . .  41 

Seizures,  epileptic        . .          . .  21 

Self-abasement  . .          . .          . .  41 

—  absoi-ption     . .          . .          . .  41 

—  abuse  . .         . .          . .          . .  41 

—  accusationsof  hypocrisy,  etc.  41 

—  confidence,  loss  of  . .          . .  41 

—  control,  loss  of         . .          . .  41 

—  disposition  to  connect  every- 

thing with  . .  . .     15 

—  esteem,       exaggerated      or 

diminished  . .  . .  41 

—  feeling,  morbid  . .  . .  41 

—  mjuring          . .  . .  . .  31 

—  injury          ...  . .  . .  41 

—  interrogation  . .  . .  41 

—  mutilation     . .  . .  . .  41 


PAGE 

Self,  repetition  of  words  to      . .     39 

—  reproaches     of     masturba- 

tion         . .          . .  . .     41 

—  talking  to       . .          . .  . .     44 

Senile  dementia            . .  117,  160 

—  insanity         . .          . .  . .   116 

—  ~  (etiology) 144 

—  —  (pathology)          ..  ..200 

—  —  (prognosis)           . .  . .   186 

—  —  (treatment)         . .  . .  263 

—  mania             . .          . .  . .   116 

(diagnosis)           . .  . .   161 

—  melancholia  . .          . .  116,  161 

—  speech            . .          . .  . .     43 

Sensation  and  perception  . .  vii 
Sensations,    initiatory,    of    an 

infant 223 

—  morbid            . .          . .          . .  84 

—  of  electric  currents  in  head  27 

—  of  fulness  in  head    . .          . .  27 

—  of  pressure  in  head. .  27,  38 

—  painful,  heat,  etc.  . .  . .  36 
Sense  of  being  controlled,  etc.  16 

—  of  heat  abolished     . .         . .  27 

—  of  ill-being 28 

Senses,  absence  of  two  or  more  41 

— •  acute  . .         . .          . .          . .  41 

— ■  deprivation  of  . .  66,  157 
insanity  from  (etiology)  138 

—  enfeebled      . .          . .          . .  41 

—  muscular,  abolished,  etc.   . .  35 

—  the  various,    to   investigate 

the  acuteness  of . .         vi,  152 
Sensibility,  disorders  of  . .   202 

—  electric,  abolished,  etc.      . .     20 

—  enfeebled,  etc.  . .  . .     41 

—  extreme         . .  . .  . .     41 

—  perverted,  etc.  . .  . .  11 
Sensiblerie,  morbid  . .  . .  214 
Sentences  uncompleted  . .  41 
Sentiments,  alteration  of  . .  41 
Seriousness  increased  . .  . .  41 
Sexual  appetite  diminished  . .  41 
lost  41 

—  desire,  loss  of  . .  . .   216 

—  excess  . .  . .  . .     21 

—  excitement    . .  42,  252,  257 

—  hallucination  . .  . .     26 

—  hypochondriasis      . .         . .     96 

—  neurasthenia  . .         . .  102 

—  organs,  examination  of      . .   153 
— •  perversion     . .  . .         42, 107 

Shutting  eyes     . .  . .  . .     42 

Sibbald'sgastro-enteric  insanity 

(etiology)  ..         ..137 

Sight,  impaired. .  ..  ..42 


GENERAL   INDEX. 


34: 


PAGE 

Similarity  of  repeated  attacks 

in  same  patient             .  .  42 

Simple  hallucinations  . .          . .  24 

—  mania            . .          . .          . .  90 

—  nielancliolia             . .          . .  94 

—  primary  dementia  . .  . .  99 
Single  patient,  duties  of  person 

having  charge  of        . .  280 

—  —  examination  of  . .  . .  279 
(private  care)      . .          . .  257 

—  —  laws     as     to      keeping, 

England  and  Wales      .  .  279 

Sin,  ideas  about             . .          . .  42 

SitoiDhobia           . .          . .          . .  42 

—  and  anorexia            . .          . .  215 
Size  and  form  of  cerebral  sub- 
stance     . .          . .          . .  191 

Skae's  classification     . .          . .  4 

Skin,  changes  in           . .          . .  42 

—  irritation       . .          . .          . .  42 

—  lesions  of       . .          . .          . .  217 

Sleep,  how  produced    . .         . .  224 

—  theories  of    . .           vii,  224,  225 

—  walking  in    . .          . .          . .  235 

Sleeplessness      . .         . .          . .  42 

Slovenly  and  untidy     . .          . .  42 

Slowness  of  ideation     . .          . .  42 

Slow  pulse          . .          . .          . .  42 

Small  head         . .          . .          . .  27 

Smell,  hallucinations  of          . .  42 

Sodii  salicyl.  as  a  bactericide . .  262 

Solitariness        . .          . .          . .  42 

Somatic  stigmata          . .          . .  42 

Sombreness         . .          . .          . .  43 

Somnambulism,  pseudo-insanity 

of 117 

—  (etiology)       . .          . .  144 

— (prognosis)     . .          . .  186 

Somnolence,  or  coma  . .  . .  15 
Sores  on  extremities,  tendency 

to 43 

Speaking,  never . .          . .          . .  35 

Special  prognosis          . .          . .  173 

Specific    gravity     of     cerebral 

substance            . .          . .  192 

Speech,  abnormalities  of         . .  43 

—  and  action,  monotony  of  . .  34 
inconsistencies  in          . .  31 

—  congenitally  absent,  etc.    . .  43 

—  or  action  limited     . .          . .  33 

—  rhyming         . .          . .          . .  40 

—  senile              . .          . ,          . .  43 
SiDermatorrhcea . .          .  .          . .  43 

Spinal  cord  in  general  paralysis  197 

—  neurasthenia  . .  . .  102 
Spitzka's  classification. .          ..  6 


PAGE 

Spitzka's  statistics  of  New 
York  pauper  asylum     .  . 

Spleen,  lesions  of 

Spontaneity  impaired  . . 

Spurious  delusions 

Squander,  disposition  to 

State  of  New  York,  certification 
of  the  insane  in . . 

—  restless,  etc.  . . 
Statement    accompanying    ur- 
gency order 

—  form  of  medical       . .      288,  290 
Statements  inconsistent,  etc.        43 
Statistics  of  frequency  of  prin- 
cipal forms  of  insanity . . 

Status  epilepticus  (treatment) 

Stigmata,  somatic 

Stomach  and  intestinal  lesions 

Stripping  naked  in  public 

Stunnings 

Stupidity 

Stupor 

—  anergic 

(etiology) . . 

(prognosis) 

—  delusional 

—  -  pathology  of 
Stuporous  insanity 

—  melancholia 
Subsultus  tendinum 
Suffering,  passive 
Suicide  or  homicide 

—  threatening  to  commit 
Suicidal  mania  . . 

—  melancholia  . . 

—  tendency 
Sulphonal  in  insomnia 
Superintendents,     medical, 

duties  of  . . 
Suppression  of  catamenia 
Suspicious  delusions 
Suspiciousness    . . 
Swelling  of  upper  lip    . . 
Symmetry,  bodily,  want  of     . . 
Symptoms  influenced  by  physio 

logical  periods    .  . 

—  morbid  anatomy  of . . 

—  motor  (morbid  anatomy)  . . 

—  of  insanity     . . 

—  of  mental  aberration 

—  treatment  of  at  home 


170 

217 

43 

18 

43 

314 
43 

273 


169 

264 

42 

217 

..     43 

..     43 

..     43 

43,  133 
117,  167 

..  144 
..  186 
..  66 
..  225 
..  117 
..  99 
..  44 
..  37 
..  248 
..  45 
..  156 
..     98 

44,  215 
..   243 

287 
44 

155 
44 
47 
14 


—  urgent,  immediate  relief  of 
Syphilitic  insanity 

(diagnosis) 

■ (etiology) . . 

—  —  (pathology) 


44 
202 
208 
240 
131 
251 
243 
118 
159 
144 
201 


344 


GENERAL   INDEX. 


PAGE 

Syphilitic  insanity  (prognosis)    186 
(treatment)         . .  . .   267 

—  pseudo-general  paralysis  119,160 
Systematised  delusions         -  . .   155 

Thtjdichum,   p.    221;    Tuke 
(Batty),     136,    191,     219; 
Tnke  (Hack),  253.  263.  316 
Taciturnity         . .  . .  . .     44 

Tactile  hallucinations  26,  44 

Talkatiyeness     . .  . .  . .     44 

Talking  to  self 44 

—  with  uncompleted  sentences     41 
Taste,  hallucinations  of  . .     44 
Teeth,  grinding  . .          . .          . .     24 

Temper  and  character,  change 

of : . 

—  change  of 

—  unequal 
Temperature 

—  of  h  ead 
Tendency  to  mischieyousness 

—  to  suicide 
TeiTuinal  dementia 

—  -  -   (diagnosis) 

—  —  (etiology) . . 

(pathology) 

(prognosis) 

Terminaler  hlodsinn     . . 

Terror      

Testamentary  capacity  of  the 

insane 
Tests  of  insanity,  legal. . 
Theomania 
Theories  of  sleep 
Therapeutics  and  hygiene 
Thought  and  action,  want   of 
continuity  in 

—  force  in 

Thoughts  and  feelings,  concen- 
tration of,  on  health,  etc. 

moyements,  monotony  of 

Threatening  to  commit  suicide 

—  yiolence  to  others 
Thyroid  gland  affected 

lesions  of 

Time,  ideas  of  incorreat 

—  reaction 
Timidity  . . 
Tinnitus  aurium 
Tissues,  lesions  of 
Tohsucht . . 
Tongue     . . 
Toi-pidity.. 
Torpor,  mental  .  . 
Toxic  insanity^  . . 


74 

45 

45 

44 

45 

34 

44 

65 

167 

138 

195 

176 

65 

45 

317 

320,  321 

..     64 

. .   224 

. .    242 

16 
23 


15 
34 
45 
45 
45 

217 
46 
39 
46 
46 

216 
89 
46 
46 
46 

120 


PAGE 

Toxic  insanity  (etiology)  . .  144 

(pathologj-)         .' .  . .  202 

(prognosis)          . .  . .  187 

(treatment)         . .  . .  267 

Transitory  mania          . .  . .  92 
(diagnosis)          . .  . .  165 

—  neurasthenic  insanity  . .  103 
Traumatic  idiocy          . .  . .  84 

—  insanity         . .          . .  . .  129 

—  —  (diagnosis)          -. .  . .  164 

—  -  -  (etiology) . .          . .  . .  145 

(pathology           . .  .  .  202 

•  (prognosis)           . .  . .  188 

Treatment  at  home       . .  . .  249 

—  of  special  forms  of  insanity  262 
-  symptoms  at  home  ' .  251 

—  remedial        . .          . .  .  .  243 

Tremor    . .          . .         . .  . .  46 

Trifles,  annoyance  at    . .  . .  12 

—  exaggeration  of        . .  . .  21 

Trophic  disturbances    .  .  . .  46 

Trunk,  rigidity  of           .  .  .  .  40 

Tumours  in  brain          . ,  . .  65 

Typhomania       . .          . .  . .  60 

Typhus  fever,  delirium  of  (diag- 
nosis)       . .          . .  . .  147 

[Jltijiate  care  and  treatment     249 
ITncertified  lunatics      . .  . .   291 

Unconsciousness,  apparent      13,  46 
Unsociability     . .  . .  . .     46 

Unsystematised  delusions    156,  158 
Untidy  and  slovenly     . .  . .     42 

Unworthiness,  ideas  of  . .     47 

Upper  lip,  swelling  of  . .  . .     47 

Urgency  order,  form  of  (Eng- 
land and  Wales)  . .   270 
statement  accompany- 
ing           . .          . .        '. .   278 

Urine       . .  . .  . .         . .     47 

—  retention  of  . .  . .  . .     40 

Uterine  insanity  . .  . .   131 

(diagnosis)  163,  164,  165,  167 

. (etiology) . .  . .  . .   145 

(prognosis)  . .  . .   188 

Uterus  and  ovaries,  lesions  of     217 

y-EBSTY,  P20. 199,  200;Virchow, 
199  ;  Voisin,  36,  39,  40,  43, 
72,  73,  74,  75,  76,  77,  78,  79, 
80,  140,  177,  197 
Vacant  expression        . .  . .     47 

Vacillation         . .  . .  . .     47 

Vague  fears        . .  . .  . .     47 

Vanity 47 

Vascular  changes  . .  . .     47 


GENERAL   INDEX. 


345 


PAGE 

Vaso-motor  paresis       . .  . .     47 

Ventricles,  the    (macroscopical 

morbid  anatomy)  . .   193 

Veratrum  viride  in  motor  ex- 
citement .  .  . .  . .   246 

Verbigeration     .  .  vi-,  siii.,  47 

Verriicktheit,  acute  primare  . .     56 

Vertigo 23,  47 

Violence  . .  .  .  .  .  . .     47 

—  threatening  to  others  . .  45 
Visceral  hallucinations  . .     26 

—  neurasthenise  . .  . .  102 
Visitation  book, form  of  medical  282 

—  of  patients 287 

Visual    disturbances      (morbid 

anatomy  of)  . .  . .   205 

—  hallucinations  . .  . .  47 
Vocal  cord  or  cords  paralysed  47 
Vociferation,  abusive  . .  . .  47 
Voices,  hearing  . .  . .  27,  47 
Voluntary  boarders  . .  261,  279 

—  movement  . .  . .  47 
Voracity  . .  . .  . .     47 

Watteville,  2)p.    252,  265  ; 
Weatherly,  257 ;  Westphal, 
56;  Wigles  worth,  36; 
Wilson     (Erasmus),     143, 
184;  Wolfenden,69;  Wundt, 
82 
Wahnsinn  . .  .  .  . .     56 

Wander  abroad,  disposition  to     47 
Wandering  lunatics      . .  .  .   294 

Weakness  . .  .  .  .  .     48 


PAGE 

3,  213 
.  14 
.  35 
.  158 
.  48 
.  48 
.  48 
.  152 
.   192 


Weakness,  general  mental 

—  in  back 

—  muscular,  limited 

—  of  will 
Wealth,  ideas  of 
Weeping  . . 

Weighing  own  Judgments 
Weight  and  height  of  patient 

—  of  brain  in  insanity 
Weir-Mitchell's    treatment  of 

nera-asthenia      . .  . .    267 

Wet  in  habits 48 

Wife  in  charge  of  husband  . .    286 

Wildness  and  intractability  . .     48 

Will,  affections  of  the  . .  . .     48 

—  weakness  of  . .          . .  . .   158 

W'ord-maldng     . .          . .  . .     47 

Words  and  acts,  paying  atten- 
tion to      . .          . .  . .     36 

—  own          . .  . .     48 

—  ideas,  automatic      . .  .14 

—  muttering  isolated  . .  . .     35 

—  repetition  of,  to  self  . .  39 
Work,  distaste  for  . .  . .  48 
V/ringing  hands  . .  . .  48 
Wrists  flexed  . .  .  -  . .  48 
Write,  inability  to  . .  . .  48 
Writing  altered  . .          -  ■  . .     48 

YotTNfG  children,  delirium  of  . .   131 

— (etiology)        . .  . .   145 

— (prognosis)     . .  . .   188 


—  congenital,  mental  or  moral  133       ZwAifGSVOBSTELLUSGEN 


29 


967.91 


JOHS    WEIGHT   AND   CO.,    PRINTERS,    BKiSTOL. 


INSANITY. 


Its  Classification,  Diagnosis  and  Treatment; 

A  Manual  for  Students  and  Practitioners  of  Medicine. 

BY 

E.  C.  SPITZKA,  M.  D., 
Professor  of  Medical  Jurisprudence  and  of  the  Anatomy  and  Physiology  of  the 
Nervous  System,  at  the  New  York  Post-Graduate  School  of  Medi- 
cine, President  of  the  New  York  Neurological  Society,  etc. 


In  this,  the  first  systematic  treatise  on  Insanity  published  in  America  since 
the  days  of  the  immortal  Rush,  the  author  has  made  its  definitions,  classifica- 
tions, diagnosis  and  treatment  plain  and  practical  ;  and  has  laid  particular 
stress  upon  points  comparatively  new  and  has  succeeded  in  presenting  the  sub- 
ject in  such  a  manner  that  the  rudiments  of  this  difficult  and  intricate  branch 
of  medicine  may  be  easily  acquired  and  understood. 

I^^This  important  work  has  already  been  adopted  as  the  Standard  Text- 
Book  in  the  College  of  Physicians  and  Surgeons  of  New  York,  the  College  of 
Physicians  and  Surgeons  of  Baltimore,  the  Rush  Medical  College  of  Chicago, 
the  College  of  Physicians  and  Surgeons  of  St.  Louis,  and  the  Medical-Chirurgi- 
cal  College  of  Philadelphia. 


1  he  Boston  Medical  and  Surgi- 
cal Journal  says:  • '  Conservative  and 
in  accordance  with  the  highest  principle 
of  scientific  investigation,  which  accepts 
no  half-truth,  but  proven  facts  alone. 
Its  chief  merit  consists  in  its 
efifori  to  present  the  subject  in  a  clear, 
accurate,  and  scientific  manner." 

The  Louisville  Medical  News 
says:  "  The  book  is  written  in  a  clear 
and  forcible  style,  and  while  the  practi- 
cal side  of  the  question  is  kept  constant- 
ly in  the  foreground,  it  abounds  in  inci- 
dents, historical  and  modern,  which 
admirably  illustrate  the  points  made  by 
the  author,  and  contribute  largely  to  the 
entertainment  of  the  reader." 


The  Weekly  Medical  Review- 
says:  "  It  cannot  be  neglected  by  any 
one  desiring  a  clear  and  comprehensive 
review  of  the  whole  subject  of  insanity." 


The  New  York  Medical  Record 

Says;  "  The  accomplished  author  dis- 
plays throughout  a  masterly  grasp  of  his 
intricate  subject,  and  a  familiarity  with 
its  bibliography  which  is  in  the  highest 
degree  commendable.  .  .  The  pre- 
sentation of  his  arguments  is  direct  ana 
decided,  his  illustrations  usually  apt  and 
well  put,  and  his  expositions  of  the 
most  important  points  forcible." 

The  Cincinnati  Lancet  and  Clinic 

says:  "A  great  variety  of  useful  infor- 
mation and  an  intelligent  discussion." 

The  American  Medical  Weekly 

says:  "  It  is  clear,  it  is  up  to  the  times, 
and  last  but  not  least,  it  is  practical." 


The  New  England  Medical 
Monthly  says:  "  By  far  the  best  book 
that  has  appeared  in  English  in  this 
department  of  Science.'' 

In  One  Large  Octavo  Volume,  424  pages.     Illustrated.    $2.75. 


E.  6.  TREAT,  Publisher,  5  Cooper  Union,  New  York. 


2gJ!<  ■i;^*'  A^WWfSSSESKJHSsais  - 


DATE  DUE 

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DEMCO  38-296 


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